US
(o2S
PROFESSIONAL PROVIDER PARTICIPATION
EPSDT - MEDICHEK
LOCAL DEMONSTRATION PROJECT
WILL-GRUNDY COUNTY MEDICAL SOCIETY
FINAL REPORT
REPORTS
RJ
102
.5
13
B76
1976
RONALD R.
EXECUTIVE
BRYANT
SECRETARY
Since 1974 the Will-Grundy County Medical Society, ini-ially
under subcontract to the Committee cn Health Care of the Poor of
the American Medical Association and later in direct contract with
the Social and Rehabilitation Service of the Department of Health,
Education and Welfare, has sought to demonstrate professional
provider participation in planning for the successful integration
of the Sarlv Periodic Screening Diagnosis and Treatment Program
into the public and private sectors of the health, welfare and
social systems in Will County, Illinois. While this report will
detail the activities of the 1975-76 contract period, it is in a
larger sense, a final statement of the role of private physicians
in a public-private partnership and the limited success in devel-
oping alternatives to traditional modes of delivery.
In understanding the 1975-76 project, it is important to
remember that the present contract is an extension and expansion
of the initial sub-contract. The 1974-75 project was devoted to
exploring alternative methods of delivery of EPSDT services in
private office settings while simultaneously attempting to fac-
ilitate entry of EPSDT-eligible children into the health care
delivery system through an active outreach program through
communication and coordination with various community agencies
offering direct or indirect services to the Medicaid-el igible
population. At the same time, efforts were initiated to address
bureaucratic roadblocks which impeded the delivery of EPSDT services.
In order to satisfy the goal of delivery of EPSDT services
in private office settings during the sub-contract period, the
Society expanded a rotation system of assignment of patients to
physicians. Under the program, Medicaid-eligible patients con-
tacted project staff and were assigned to a volunteer pool of
physicians. To increase public awareness of the program, outreach
was directed through the local Department of Public Aid and through
local schools. Project staff developed record-keeping mechanisms
to handle the assignment of patients to physicians and to record
the results of those contacts. Since the system was maintained
through the second contract period, a description of the patient
enrollment and family history files appears latar in this report.
In an attempt to minimize bureaucratic roadblocks, physician
volunteers submitted claim forms to the project office rather than
directly to the Illinois Department of Public Aid. A system of
prior claim review was developed to eliminate clerical and billing
errors which delayed payment to physicians by the State of Illinois.
As an additional service, project staff provided training to pri-
vate office personnel in the preparation of complicated forms.
A second major activity of the 1974-/5 subcontract was the
participation of the Society in a mass screening program of elemen-
tary school children who had failed to complete physical examina-
tions as required by state law. The mass screening program, co-
ordinated with the Will County Health Department and Joliet Grade
School District 36, provided an opportunity to identify 2PSDT-
eligible children and bring them into the program. Although over
six hundred children were examined in the program, problems of
confidentiality hampered identification of SPSDT-eligibles . The
orogram did result in development of an outline to address these
problems and to improve the educational opportunities of the
program. This outline was included as an integral portion of the
1975-75 contract.
The physician rotation program was discontinued prior to the
completion of the 1974-75 subcontract. The termination was the
joint result of a successful outreach program which increased the
number of patients at greater numbers than they could be assimilated
into the system combined with a steady decrease in voluntary
physician participation in the program. The decrease in physician
participation was generally attributed to three factors:
A. Patient overload infringed on the delivery of medical care to
established patients.
B. The Medicaid payment system of the Illinois Department of
Public Aid was unresponsive to the increasing cost of deliv-
ering medical care and, therefore, the program was not
economically sound,
C. Patients did not conform to office routine, i.e., a high rate
of missed appointments, demanding attitudes, and over-
utilization of services.
Thus, although local project staff was able to develop a
record-keeping mechanism, and although EPSDT services were deliv-
ered, the experience of the 1974-75 contract posed major problems
for the Society in meeting the terms of the contract:
A. The failure of attempts to establish meaningful ccmmunication
with the Illinois Department of Public Health and the Illinois
Department of Public Aid which jointly share administration
of the EPSDT program, designated as Medichek in Illinois.
The program carried a low priority in both departments and
attempts to resolve bureaucratic problems which increased
the level of physician frustration were not seriously con-
sidered by either department.
(3)
3. Failure to resolve the problem of confidentiality. Although
t.-.e Society was willing to explore means of providing services
to EPSDT-eligible children, we were consistently unable :c
locate eligibles due to the nature of federal and state
statutes which protect the identity of public aid recipients.
The solution to this problem was beyond the authority and
capability of the Society at a local level and a solution was
not forthcoming at a state or national level.
C. The growing frustration of physicians to the apparent unres-
ponsiveness of the Illinois Department of Public Health, the
Illinois Department of Public Aid and the Social and Rehabil-
itation Service of the Department of Health, Education and
Welfare to long-identified problems combined with the diffi-
culties of dealing with public aid patients in private settings.
Many problems were initially identified in "A Report on Pro-
fessional Health Provider Participation - EPS DT - Medicaid -
1974", and in fourteen specific problem areas discussed in
the final report of the 1974-75 subcontract project.
D. A growing shortage of primary care physicians in the area
resulting in growing patient loads as population of the area
increased.
The role of the American Medical Association during the sub-
contract period was to serve as a fiscal intermediary, to assist
in creation of an administrative mechanism and to provide tech-
nical staff support in operation of the local demonstration project.
The vehicle was the AMA ' s Committee on Health Care of the Poor.
Because the Committee could not see progress in solving problems
previously identified in "A Report on Professional Health Provider
Participation - EP S DT - Medicaid - 1974", near the end of the
subcontract period, the Committee decided that little could be
accomplished by continuing. While the American Medical Association
recommended discontinuation in direct participation with the
Department of Health, Education and Welfare, AMA did offer to
assist the Will-Grundy County Medical Society if the local society
decided to continue the project. Despite the continuation of long
identified program problems, the Social and Rehabilitation Service,
Medical Services Administration, Department of Health, Education
and Welfare urged the Society to accept a direct contract to con-
tinue the project with the proviso that the American Medical Assoc-
iation accept a subcontract for second-year activities. Pressure
was applied to the Society through project staff by Medical Services
Administration staff members at an evaluation meeting which followed
the mass school screening program in April, 1975. This view pre-
vailed over the reluctance of many physicians involved in the
(4)
The major elements and timetable of the 1975-7-5 ~ontrac_
were jointly developed by staff of the Social and Rehabilitation
Service of the Department of Health, Education and Welfare and
local project staff in a period of less than thirty days. Many
physicians were unaware of the scope of these developments. The
intent of the new contract was to continue to seek means to
develop and improve communication between the public and private
sectors and to explore new means of delivering EPSDT services.
This intent was expressed in the statement of purpose in the
scope of work of the new contract:
"The purpose of this project is to explore alternative
solutions to providing the assistance needed by professional
health care providers attempting to meet EPSDT needs in solo
practice settings and to develop a model whereby individual
professional health care providers will be involved in a Com-
munity Health Services Program which draws upon existing resources
and those that can be developed through a coordinated effort of
all related community agencies and services including the schools,
under the sponsorship of the local Medical Society".
Implicit in this statement of purpose is commitment of con-
tinuation of project activities developed during the subcontract
period and a major expansion of the project with development of
the Community Health Services Program. The hurried development
of the new contract would later prove to be a major weakness
which would require considerable time and effort to repair.
(5)
THE AREA
It is important to provide a description of the area against
which the project has been projected daring both contract years.
Will County, one of the most rapidly growing areas in the State
of Illinois, covers 845 square miles in the northeastern section
of the state. The county is within fifty miles of Chicago and is
adjacent to the counties of Cook, DuPage, Kane, Kendall, Grundy
and Kankakee in Illinois and Lake County, Indiana. The population
of Will County in 1970 was 249,498, an increase of 30.2% since
1960. Will is the seventh largest of 102 counties in Illinois and
the county's growth rate from 1960 to 1970 was exceeded by only
two other counties in the state. The population pattern for the
county shows an 11% growth rate from 1970 to 1973 with a 1973 census
of 278,060. The majority of Will County is rural with two heavily
urbanized areas located in the northeastern and northwestern por-
tions of the county. The city of Joliet, with a population in
excess of 78,000, located in the northwestern quadrant of the
county, is the governmental, educational and cultural center.
Joliet, with its adjoining metropolitan area, has been the center
of activity during both contract periods. The 1970 population of
the metropolitan Joliet area, encompassing four townships was
160,960, representing 64% of the population of the entire county.
Two of the townships in the metropolitan area registered a more
than 30% growth rate between 1960 and 1970.
The Will-Grundy County Medical Society has 176 member phy-
sicians in solo and group practices in Will County, 150 located
in the metropolitan Joliet area. The area is served by two general
hospitals with a total of 983 beds offering physical therapy, in-
tensive care and cardiac care, psychiatric care, and accredited
schools of nursing, medical technology and radiologic technology.
Other health resources include twelve long term care institutions
with 794 beds and 91 dentists. In addition, the Will County Health
Department, headquartered in Joliet, has divisions dealing with
mental, dental and environmental health, health education and
nursing services. A variety of related social and welfare services
is provided by 149 public and private community agencies in Will
County .
The continued pattern of rapid growth in Will County, and
particularly in the metopolitan Joliet area, have taxed the capa-
city of existing resources to meet the ever-increasing demand for
health services. This problem is intensified by a steady decline
in the availability of primary care medical services since 1964.
(65
Approximately 53 physicians left private practice in Will County
between 1964 and 1975, 4 6 in the categories of family practice,
pediatrics, internal medicine and obstetrics. During the same
period, 67 physicians entered practice but only 26 in the primary
care, some part-time. The result was a net loss of 22h primary
care physicians during a period when the population of the county
increased over 30%. The ratio of primary care physicians to
patients in the metropolitan Joliet area is 1/3,499, however,
physicians do not restrict their practices to residents of that
araa. Most residents of rural areas of Will County are dependent
on health care facilities in the metropolitan area, thus the ratio
of primary care physicians to the population of the county is
1/6,045. This overload has caused many physicians to restrict the
size of their practices. These restrictions of practices resulted
in an increase of crisis oriented delivery in local hospital
emergency rooms particularly for the low income segment of the
population .
These problems, coupled with the lack of education of the
general public in health matters, a serious transportation in-
adequacy in the metropolitan Joliet area, the clustering of a
majority of the public aid recipients of Will County in the Joliet
metropolitan area and growing physician resentment of the non-
responsive bureaucracy of the Illinois Department of Public Aid,
have erected significant barriers to health care. These barriers
have served to perpetuate cycles of illness, limited health aware-
ness, education and poverty, particularly frustrating the poor
and alienating them in their relationship to society. It is
estimated one or more of these barriers to health care affects
up to 39% of the population of the Joliet metropolitan area.
The involvement of the Society in the EPSDT Program was
an attempt to isolate and resolve some of these barriers to health
care delivery, however, that involvement was increasingly tempered
by the attitude of the medical community. That attitude, hopeful
in the beginning, became increasingly discouraged over the two
years of the project, particularly during the 1975-76 contract
period. The discouragement was fueled by the shortage of primary
care physicians, the already existing patient overload, the pre-
viously described difficulties in treating public aid patients,
and frustration with the public aid system and the unresponsiveness
of the State of Illinois in responding to physician problems and
concerns. Another problem contributed to the steady erosion of
physician interest and participation in the EPSDT Program, a
generally shared belief that the majority of malpractice litigation,
particularly non-meritorious suits were initiated by public aid
patients. This belief was only a part of a much larger concern
with the entire malpractice problem as experienced by physicians
but it added a significant piece co the growing mosaic of physician
(7)
It is not unusual that the Will-Grundy County Medical Society
should choose initially to become involved in the SPSDT Program.
The recan- history of the Society has been one of involvement in
the creation of community agencies related to federal health pro-
grams and community problems. Since 1969, the Society has initiated
or assisted in the development of a community drug abuse program
and a comprehensive health planning agency. The Society founded
the Quad River Foundation for Medical Care, the only operative
Professional Standards Review Organization in Illinois in 1975.
In each instance, the Society committed considerable volunteer-
physician time and resources as well as financial and staff support.
In each instance, the Society provided office space to the fledgling
organizations. It was with this history that the Society accepted
involvement in the Early Periodic Screening Diagnosis and Treatment
Program. Having been successful in previous endeavors, the Society
entered the 1974-75 sub-contract with high expectations. Despite
the lack of progress evident at the end of that period, the Society
retained enough confidence in it's ability to overcome obstacles
to accept a second contract despite advice to the contrary from
the AMA . Even when severe administrative problems had surfaced
after signing of the 1975-76 contract, the confidence of physicians
was such that, followinga site visit, Elsie Tytla, M.D., medical
advisor to the Medical Services Administration of the Department
of Health, Education and Welfare, was prompted to comment:
"My general impression is that this is an unusual, highly
motivated, activist county medical society. It has the only
designated and operational PSRO in the entire State of Illinois.
It has intense desire to be creative, constructive and successful
but is unable to overcome a series of unfortunate events over
which they had little control." 2
Elsie Tytla, M.D., Report on visit with Will-Grundy County
Society-September 23, 1975, iatsd September 30, 1975.
(8)
PHASING INTO SRS 500-75-0030
The "series of unfortunate events" described by Doctor
Tytla actually began develop prior to initation of the 1975-
76 contract. As reported earlier, the staff level negotiations
of the scope of work of the contract were completed in a brief
period of time and the substance of these negotiations were not
presented to physicians of the Society. Thus the contract was
encered without a clear understanding of its terms. Indeed the
committee with primary responsibility for the EPSDT Program, the
Public Health and Medical Services Committee, had voted not to
recommend a second contract to the Society's Board of Directors.
The Board of Directors did not receive that recommendation, in
fact, did not officially consider the second contract. The docu-
ment was approved later on recommendation of the Executive Com-
mittee. An ad-hoc physician committee was created, by staff, to
work with other community organizations to resolve problems en-
countered following the collapse of the physician rotation program
during the 1974-75 contract. This ad-hoc committee, aware of only
one area of program development, represents limited physician
contact in development of the new contract. In effect, the 1975-
76 contract was primarily a staff document, concieved, written,
finalized and signed at that level. The respective roles of the
Society and the Department of Health, Education and Welfare were
not defined at a decision-making level in the Society. Although
the new proposal mandated development of a sub-contract with the
American Medical Association, no guidelines were provided or
developed to specify the role of the AMA in the project. The
roles and responsibilities of the major parties to the contract
would not become clear in the Society until several months had
passed. This was acknowledged by the Department of Health,
Education and Welfare when Doctor Tytla reported:
"This project scope of work is way beyond the capabilities
of this Medical Society and its staff at this time who
wrote up the proposal is no longer there is a good project
director but needs help in the health care delivery field. The
active physicians are all practicing specialists who honestly want
to produce something useful but need help Mot only has there
been no cooperation from Welfare but no response to any suggestions
in Medichek procedures from the State Health Department either.
IN ADDITION, WE AT THE CENTRAL OFFICE HAVE NOT RESPONDED TO ANY
OF THEIR PLEAS . " 3
Tytla, M.D., Report cn visit with Will-Grundy County Medical
y, September 23, 1975; dated 3 apt amber 30, 1975.
* 9 )
By September 1975, it was claar that the Department of Health,
Education and Welfare had negotiated the contract in lass than
good faith in rarms of the technical support and assistance to
the Society in meeting the scope of work in the contract.
10)
MAJOR PROJECT ACTIVITIES
The departure of key staff personnel from the Society and
confusion over assignment of project personnel at the Department
of Health, Education and Welfare put the Society in a position
of not having a project officer at a crucial time. The confusion
in staff identity at Department of Health, Education and Welfare
persisted from July to November 1975. With new personnel at both
ends of the project, unacquainted with each other or with the
nature and background of the project, the Society was faced with
the responsibility of defining specific areas of activity to meet
the scope of work of the contract. These activities were broadly
defined into three general areas :
A. Discussions with state and national leadership relating to
specific EPSDT program barriers.
B . Development of a Community Health Services Program to explore
alternate methods of delivery of health care to the Medicaid-
eiigible population including but not restricted to EPSDT-
eligible children.
C. Continuation of administrative assistance in the delivery of
EPSDT services in private office settings combined with develop-
ment of community outreach programs and patient-oriented health
education materials.
The implementation of each of these program areas has been charac-
terized by a nearly total breakdown in communication between the
Society and the Department of Health, Education and Welfare leaving
the project in a vacuum.
The single exception to the communications breakdown was in
the relationship of the Society to the American Medical Association.
Staff members from the Department of Rural and Community Health
assisted local project staff in development of a formal sub-contract
and maintained their involvement in, and concern for the project.
American Medical Association staff provided virtually the only
link in continuity between contract periods. Throughout the 197 5-
75 contract period, the American Medical Association proved to be
the only reliable source of technical assistance and materials for
local project staff. As late as April, 1976, project staff was
verbally informed by the Department of Health, Education and Welfare
that materials were available to assist in planning and decision
making but the information was never forwarded.
In a visit to the Department of Health, Education and Welfare
shortly after initiation of the 1975-76 contract, project staff
(115
expenses resulted in such a severe cash flow shortage that the
project was nearly forced into suspension in three months when
local staff could no longer meet expenses.
To resolve this difficulty and assist in implementing the
three general areas of activity previously mentioned, physicians
and project staff designed a mechanism of quarterly activities with
specific goals in each contract quarter. A verbal agreement was
obtained with the Department of Health, Education and Welfare al-
lowing the release of withheld funds at the end of each quarterly
period. The Society was not assisted by the Department of Health,
Education and Welfare in this re-evaluation. As was the case through-
out the contract, the Department relied on sporadic verbal contact
with local staff.
In November, 1975, a growing frustration on the part of the
Society was expressed in a letter to Mrs. Beatrice D. Moore, Acting
Director, EPSDT Division, Department of Health, Education and Welfare
from the president of the Society:
"We would make only four (4) requests as we submit these
reports :
A. That someone read them in their entirety since they were re-
quested in precisely this form.
B. That those who read them will understand that they were
written slowly, carefully and sincerely.
G. That the authors, approximately fifteen (15) people, really
believe that Medichek is a good idea and with changes can
live and grow, but without changes will surely die a horrible
death .
D. That someone initiate some changes seen before the frustration
level of Will County primary care physicians exceeds their
patience with those who keep encouraging them to try again."
There was no response from the Department of Health, Education and
Welfare .
With this general background and an understanding of the dif-
ficulties which attended initiation of the 1975-76 contract, we
can examine the operation of the project.
Albert w. Ray, Jr., M.D. letter to Mrs. 3eatrice Moore, dated
(12)
DISCUSSIONS WITH STATS AND NATIONAL LEADERSHIP
RELATING TO SPECIFIC EPSDT PROGRAM BARRIERS
One of the major barriers to delivery of EPSDT services
identified in the 1974-75 contract was the participation of the
Illinois Department of Public Health and the Illinois Department
of Public Aid in the program. In the 1975-75 project, the Society
viewed its role as that of advocate for the Department of Educ-
ation and Welfare in addressing problems of inadequate provider
re-imbursement , lengthy delays in provider r e - imbur s ement , in-
creasing the generally low priority of EPSDT at the state level
and the simplification or removal of bureaucratic paperwork which
hampered delivery of EPSDT services in the private medical com-
munity. Several specific activites were initiated to address
these problems.
A. Discussions with the Illinois Department of Public Health
and the Illinois State Medical Society to re-design the
EPSDT reporting form.
B. Testimony before the Legislative Advisory Committee on
Public Aid, a joint committee of the Illinois General Assembly.
C. Development of an internal system of prior claim review
and training of office personnel for patricipating physician
members of the Society.
Discussions with IDPH and ISMS
It was assumed that revision of the EPSDT claim form would be
relatively simple. In September, 1975, project staff met with
representatives of the Illinois Department of Public Health,
Illinois Department of Public Aid and the Committee on Govern-
mental Health Program Reimbursement of the Illinois State Medical
Society. The meeting was the first between the Society, the two
state code departments and the State Medical Society to discuss
specific revisions since the involvement of the Society in April
1974. A series of eleven (11) specific program recommendations
were submitted by project staff and physicians and the Illinois
State Medical Society to representatives of the two state depart-
ments. The recommendations were:
A. M-M-R- Vaccine to be included within Program extending to
age 10 with provisions made to update children who have not
been immunized against mumps.
3. Incortor ation of newborn examination into the Medichek
3 2 3? fi a 1 3 ncr ^rccr^ram.
C. Closer coordination of Medichek with IDPA diagnosis and treat-
ment components.
(13)
D. Make provisions within program to allow private provider to
be aware of vision and hearing results on patients.
S. Need for greater coordination of outreach and education
throughout the state.
F. Consideration of including a learning disability screening
test within the Program allowing payment to providers . Ident-
ification of referral sources for foiiow-up must be identified
and the adequacy of those referral sources to absorb children
identified through screening.
G. If newborn examination included in screening package and budget
requires the exclusion of other examinations, the following
changes were recommended; drop eighteen month visit, combine
three and four year, combine five and six, coordinate ten and
fourteen with required fifth and ninth grade exams and combine
seventeen- twenty .
H. Developmental appraisal reporting should be changed to allow
for the report by the physician and also should allow the
physician to administer a specific test of his choice and
report the results of his test.
I. Urinalysis-allow physician to run a routine urinalysis and pro-
vide payment for the procedure, and have the dipstick urine
test be made part of the routine exam without payment provided.
J. There is concern as to the over-immunization problem on
children and there is a need to provide local feedback to
physicians on immunization status of children .
K. Claim form revision-consider possiblity of devising a billing
form suitable to IDPA and Medichek reporting requirements and
set the form up in a similar format such as the AMA Health
Insurance Claim Form which all physician offices are familiar
with. 5
Representative of the Illinois Department of Public Health and
Illinois Department of Public Aid were not authorized to make com-
mitments to basic program changes and indicated that ediroriai re-
vision of the claim form, as requested in point 11, would take
approximately six months.
Will-Grundy County Medical Society SRS Project-Monthly Project
Report, September, 1975.
(14)
Although consideration of. and further discussion on, either points
was promised, there were no further meetings on those topics. In
February, 1976, the revised claim form was reviewed by project
staff and the Committee on Governmental Health Program Reimburse-
ment of the Illinois State Medical Society and a representative of
the Illinois Department of Public Health. Although several ad-
ditional specific editorial changes in the claim form were suggested,
the overall reaction was later summarized by the Illinois State
Medical Society:
"Overall, the physicians felt that the changes in the form
would have little effect upon the major problems in the Medichek
(EPSBT) Program. The form is long, difficult to use and understand
though it is considered better than the previous one." °
There were no further discussions or communications with the Illinois
Department of Public Health on this relatively simple matter.
Separate discussions were initiated with staff members of the
Illinois Department of Public Aid in an attempt to further clarify
private provider concerns with state administration of the EPSDT
Program and to discuss those concerns through the local project.
It is important to remember that the Society had been attempting to
begin discussions of this nature since the beginning of its in-
volvement in the EPSDT Program in 1974. It was felt the discus-
sions were necessary in order to relate the local project to the
state program. The Society also believed it was fulfilling its role
as advocate for the Department of Health, Education and Welfare by
opening detailed discussions with the Illinois Department of Public
Aid .
What follows is a summary of major provider concerns and staff
responses from the Illinois Department of Public Aid from a meet-
ing in October 1975:
A. We questioned the nature of the responsibilites of a new Pro-
vider Relations Unit in the Illinois Department of Public Aid
and asked about coordination between the new Unit and the EPSDT-
Medichek Program of the Illinois Department of Public Health.
State staff responded that the new Provider Relations Unit would
assume responsibility for provider enrollment in the Medicaid pro-
gram and would provide provider education for state vendors. Under
the educational component, we were told that state staff would be
made available to private offices, on request, to assist in proper
claim form preparation and systems operation.
°Larry 3. Bcress, Illinois State Medical Society, letter to
(15)
In addition, the Unit was assigned the development of a monthly
newsletter to providers detailing Medicaid program changes and
providing status reports on development of the Medical Management
Information System. Mo direct relationship between the Provider
Relations Unit and the EPSDT/Medichek Program was detailed. Al-
though sporadic copies of the monthly newsletter were received
during the balance of the contract period, no other evidence of
the operation of the Unit was provided to local project staff.
3. We inquired about EPSDT activities in other areas of the state
and requested information to contact the operators of other
local projects with the goal of exchanging information on
successful project activities.
State staff verbally provided information on the operation of EPSDT
projects by several county health departments in other areas of
Illinois and promised follow-up information which was never received.
C. We asked about long range plans to identify Medichek-eligible
children not presently receiving services and about plans to
intensify outreach efforts to draw them into the program.
IDPA staff indicated that the Medical Management Information System
might develop the capability to identify EPSDT-eligibles not re-
ceiving services but said the Department would not solicit medical
visits. State staff expressed the belief that outreach would not
be intensified because of the fiscal crisis faced by the State of
Illiinois in the Medicaid program. This statement served to con-
firm the Society's impression that the EPSDT program suffered a
low priority at a state level and would continue to do so. Since a
basic tenent of EPSDT is to locate eligible children and enroll them
in a continuing program of screening, and since an active outreach
component is necessary to locate eligibles and to keep them enrol-
led, the reluctance by the Illinois Department of Public Aid to
conduct active outreach for economic reasons casts a negative re-
flection on the probability of program success.
D. Since the Society was concerned about the use of EPSDT educational
materials and wished to explore the possibility of coordinating
the development of patient-oriented educational materials through
the local project with state activities, we inquired about
materials currently available to public aid staff at the county
level .
We were informed that the development of educational materials on
EPSDT had been limited to a handout pamphlet and a packet designed
for use by professionals and related service workers outlining the
(16)
provisions and administrative structure of the EPSDT/Medichek
program. An annual mass mailing of the handout pamphlet is the
chief means of distribution of information to public aid recipients.
State staff also outlined plans for development of educational
programs for county level staff and development of a pamphlet for
the mothers of newborns. We did not learn if this activity was
completed. The development of educational materials for the mothers
of newborns is of questionable value since the State of Illinois
does not include newborns in the EPSDT/Medichek program.
E. With patient transportation remaining as a major barrier to the
delivery of SPSDT services, we inquired about the policy of the
Illinois Department of Public Aid regarding transportation al-
lowances for medical care.
State staff responded that medical care transportation was generally
provided to recipients as follows:
1. Vendor payment to a company, private taxi or public mass
transit, for example, is available but requires prior ap-
proval and a company agreement before delivery of the
transportation service.
2. Mileage r e- imbursement at a pre-arranged rate with a
volunteer. This method requires a considerable amount of
time, state staff indicated sometimes in excess of two months.
It was indicated that medical care transportation allowances were
restricted when the State of Illinois implemented a flat grant pay-
ment system replacing a need item payment system. It is apparent,
from the information provided, that medical care transportation is
difficult for recipients to obtain, again causing a negative im-
pact on the delivery of EPSDT services with its mandated schedule
of medical visits.
F. In an attempt to further explore the administrative commitment
to EPSDT at a state level, a series of general questions were
posed relating to the amount of informational exchanges among
county level EPSDT/Medichek coordinators, the future of un-
filled staff positions in the EPSDT/Medichek program and the
duties of county level coordinators.
State staff responded that there was not a regular program of
meetings for county level staff to discuss program problems and
successes and that no state-wide meetings for county level staff
had been conducted to discuss program changes since early in 1975.
(17)
It was felt that due to fiscal limitations, several vacant adminis-
trative positions in the Medichek program in the Illinois Depart-
ment of Public Health would not be filled. It was acknowledged
that Medichek coordinators at a county level were salaried through
the 75/25 federal matching formula provided through federal EPSDT
regulations although activities of these workers were considered
part of service activity and most were assigned other duties as well.
This was particularly important to local project staff since a
major local problem was the lack of a Medichek coordinator in the
county public aid office.
G. We asked about the involvement of other governmental or private
agencies in the EPSDT/Medichek program other than the Legis-
lative Advisory Committee on Public Aid of the Illinois General
Assembly .
State staff indicated that no other governmental agencies or commit-
tees and no other private agencies or organiztions were actively
involved in the EPSDT program. There was an indication that a
welfare rights group had filed suit against the State of Illinois
for failure to implement EPSDT early in the development of the pro-
gram, but state staff was unable to report on the outcome of the
suit .
H. General inquiries were posed relative to the state of the
relationship between the State of Illinois and the Department
of Health, Education and Welfare concerning development of the
EPSDT program. We specifically inquired about the state re-
sponse to the publication of proposed penalty regulations.
State staff declined to discuss these questions with local project
staff without written authorizations from the Director of the De-
partment. We were informed that the Director has responded to the
publication of proposed penalty regulations but since the response
was over his personal signature, state staff declined to discuss
the nature of the response without the Director's personal author-
ization.
As the summary illustrates, many areas of discussion were
opened however there was no follow-up to these initial discussions
by the Illinois Department c: Public Aid. It should also be
noted that IDPA staff reviewed and approved a draft of the report
of the discussion prior to its inclusion in the October 1975 monthly
progress report of the local project to the Department of Health,
Education and Welfare. Local staff reaction to the exploratory
discussion was also reported:
(13)
"As a result of the IDPA meeting, project staff became more
aware of the reality of the financial limitations currently being
on the Department of Public Aid in the State of Illinois. The
Governor has ordered 6% cuts in all State Departments and in ad-
dition, fifty million dollars was withheld from the Public Aid
appropriation for fiscal 1976. These cuts, in addition to the
imposition of a statewide freeze in hiring new employees signif-
icantly affects and limits Illinois' ability to implement a mean-
ingfull and effective EPSDT Program. In addition, I question the
Departments' ability to provide the services required by law to
categorically eligible persons in the State. Vacant desks were
evident in Springfield offices and Will County in particular is
understaffed with approximately 3-6 uncovered caseloads of approx-
imately 180 cases each affecting approximately 540 to 1080 people.
This means locally, eligible families are not being afforded the
services and attention required by law, and at the administrative
level in Springfield position vacancies prevent efficient manage-
ment of Department functions.
It is within these limitations that the Department of Public
Aid is implementing EPSDT in Illinois. Budget cuts have been in
most every medical assistance program including the drug program,
physician services, long term care programs, hospital payment pro-
grams, etc. Only two medical programs sponsored through the De-
partment of Public Aid were left unscathed. Family Planning and
Medichek. This action, as token as it may be, appears to be the
singly, most significant step the Department has made in implement-
ing EPSDT. The fact that they did not lump Medichek with the rest
of the medical programs is a hopeful sign that someone recognizes
the importance of the Program and its apparent effect on AFSC federal
matching funds.
Project staff attempted to point out the apparent weakness of the
program as perceived locally in the questions asked, but more im-
portantly attempted to show the willingness of project staff to work
for a more effective, meaningful and successful program of EPSDT
in Illinois. Earlier in the contract at the IDPH, IDPA and ISMS
meeting, staff gladly volunteered project time to serve on any com-
mittee or task force appointed to work in the area of EPSDT.
This offer was made again to IDPA staff including the Public In-
formation Office, Medichek Supervisor and the Acting Chief Bureau
of Medical Services. It appears however, that the enthusiasm for
program improvement by project staff is not shared by the responsible
authorities in Springfield. Unfortunately, it appears that Illinois
will continue to slide by with the EPSDT Program until such time
the Department of Health, Education and Welfare exercises its
(19)
authority by imposing the 1% penalty for failure to implement the
program . " '
In a future attempt to broaden communication at a state level
and as a result of information gathered in staff level discussion
with the Illinois Department of Public Aid, local project staff
prepared a report on the involvement of the Society in EPSDT for
presentation to the Legislative Advisory Committee on Public Aid
in November 1975. The Committee is a bi-partisan joint Senate House
watchdog committee of the Illinois General Assembly which has been
successful in introducting some reforms in the public aid system in
Illinois. The report, delivered by Albert W. Ray, Jr., M.D.,
president of the Society, summarized a number of problem areas in
the EPSDT/Medichek program:
A. Medichek program given low priority by state and local depart-
ments of public aid and public health.
B. Difficulty in reaching the Medichek-eligible child-the prob-
lem of confidentiality.
C. Strong identity with Illinois Department of Public Aid hinders
program acceptance by physicians.
D. Medichek is adminis tratively-not service delivery-oriented.
E. Failure to develop patient-oriented educational materials.
F. Failure to provide for diagnosis and treatment of develop-
mental disabilities.
G. Inadequate staffing at Will County Department of Public Aid.
H. Inadequate knowledge of abnormal r eports-direc tly related to
the problem of confidentiality. 8
The testimony also summarized special local problems and pointed
out the Society's difficulty in dealing with the Illinois Depart-
ment of Public Aid and Illinois Department of Public Health since
1974. A list of eight specific recommendations was also presented
A. Newborns must be covered under the Medichek program.
B. Medichek reporting forms must be reviewed.
7
Will-Grundy County Medical Socety, SRS Project, Monthly Progress
> c t o b e r 1375.
^Raccr- of the Will-Grundy County Medical Society on EPSDT/Medichek
Program for the Legislative Advisory Committee on Public Aid,
November 17, 1975.
(20)
C. A mechanism must be devised whereby Medichek-eligible patients
can be identified and included in the program without violating
confidentiality.
D. Staffing of public aid offices at both local and state levels
must be augmented to cope with the project. This might include
an EPSDT coordinator.
S. Active outreach programs must be instituted by lecal public aid
departments .
?. Must develop and effectively distribute consumer-oriented health
education materials to emphasise the importance of preventive
care .
G. Utilize centralized facilities, schools if necessary, for
screening purposes.
H. Provide for automatic replacement of vaccine administered to
Medichek patients. '
It was the intent of this presentation to enlist the support of the
Legislative Advisory Committee on Public Aid in opening communi-
cation with the two state departments at a decision-making level.
We were advised to anticipate further contact from the Committee in
January, 1976, after Committee staff had reviewed our presentation
but there was no follow-up and no further contact with the Committee.
The Society also had little success in communicating with the
Will County Department of Public Aid. The local office suffered
a severe shortage of personnel from August 1975 through February
1976 as a result of a statewide moratorium on hiring instituted
by the Governor. In addition, the local supervisor was transferred
in November 1975 and was not replaced until January 1976. Attempts
to reopen communication following the appointment of a new super-
visor also failed. In January 1976, project staff, Doctor Ray and
a state representative met with the new supervisor to introduce
the Society's project, to discuss the possibility of the transfer
of project records to the local office following termination of
the contract and the development of a mechanism to allow the local
office to continue the services of prior claim review and foilcw-
up being provided the medical community through the project office.
Although an offer to use project staff to provide EPSDT training
for new public aid employees was accepted, there was no response
to our other overtures.
The Society's growing sense of futility in gaining input at a
state or local level was compounded by what was percieved locally
as a lack of supportive involvement by the Department of Health,
Education and Welfare. From July, 1975, until January, 1976, it
was our impression that the Department would initiate a review of
the Illinois EPSDT program to determine if the State of Illinois
was out of compliance with basic program regulations. It was
further our belief that some of the documented lack of responsive-
ness on the part of the State to this project would be considered
in that review. Accordingly, the Society commented on the proposed
penalty regulations as published in the Federal Register, Volume
40, N . , 162, dated August 20, 1975:
"The delivery of EPSDT services is not, and should not, be a
yes or no, accept or refuse proposition. Rather, these services
should be an educational process of helping people understand that
regular medical and dental care, in combination with healthful
eating habits and moderate physical activity provide ingredients
necessary to insure good health.
"Public aid recipients are already innundated with reams of
papers requiring signatures for such things as medical information,
insurance information, verification of school attendance and agre-
ements to cooperate in support enforcement activites to name a few.
It is our considered opinion that requiring an additonal signature
for the purpose of accepting or refusing EPSDT services is not the
most effective means by which to inform recipients of these services.
"We believe a federally-supported program, with funds specified
for employment of individuals to provide outreach and follow-up
services and supportive health education is a more beneficial and
effective means of informing Medicaid-eligible families of EPSDT
services. It is further our opinion that additional complication
of a physician's office routine by requiring another form docum-
enting diagnosis and treatment will antagonize the medical com-
munity and will result in decreased participation by the very
people needed to insure finding' and treating all problems ident-
ified in screening." 10
Our interest in and anticipation of a review of the Illinois
program was also confirmed a: a staff level:
Albert W. Ray, Jr., M.D. letter to Administrator, Social and Re-
habilition Service, Department of Health, Education and Welfare,
da~sd September 18, 1375.
"As we understand the situatxon . . . . the state must submit a
program improvement plan by October 30, 1975 and a penalty decision
will rest on that plan.
"The central office position in this matter is important to
this Medical Society since we have begun to develop documentation
on the problems of the Medichek program for possible presentation
to a legislative sub-committee which oversees the operation of
IDPA. We were concerned that this presentation would be pointless
if the Department of Health, Education and Welfare felt the state
was not out of compliance." "
At the local level, the belief persists that only direct inter-
vention by the Department of Health, Education and Welfare can
increase the priority given EPSDT by the State of Illinois. This
belief was first expressed in correspondence to project staff at
the Department of Health, Education and Welfare in October 1975:
"Pursuant to our telephone conversation of October 7, 1975,
we agree with your assessment that the State of Illinois will be
of small assistance in the local level implementation of the EPSDT
program... The State of Illinois has provided very little assist-
ance to this project and we have little reason to expect a change
in the position. We will not be a factor in any decisions de-
claring Ilinois to be out of compliance but we are concerned that
some of our communication difficulties with your office has been
caused by a preoccupation with implementing a penalty on the State.
This preoccupation has existed in both the Central and Regional
office . "
"The failure of the State of Illinois to provide meaningful
assistance in the implementation of EPSDT can be directly traced
to the very low priority placed on the program in the Department
of Public Aid and the Department of Public Health. You will note
in our September progress report that we participated in a staff
level meeting with representatives of both departments and that
it was the first meeting of this type since our involvement in
April of 1974. We feel some progress was made in that meeting but
it failed to address the greatest weakness in the system, i.e.,
that EPSDT in Illinois is not service delivery oriented."
Ronald R. Bryant, letter to Phillip Otto, Department of Health,
Education and Welfare, dated Octer 23, 1975.
"We are confirming by -his letter that our contact with the
Region 7 office has been very sporadic, and again we will offer to
be'a resource in further dealings with the Stace of Illinois." 12
Although local project staff was unaware, these views were
receiving independent and official confirmation:
"Due to the reorganization of the state agency and turnover
in State staff (three Sta-e agency Medichek Coordinators
since March, 1974) the Stare has encountered considerable diff-
iculty in establishing a high priority program and developing
procedures to assure effective reportable county implementation.
The State's Medichek program is not effectively operationalized at
the county level for this reason."
"The major weakness in the State's Program relate to its
difficulty in obtaining and submitting reports on the number of
children who receive complete screening examinations; the lack of
a State computerized tracking system; the failure of local offices
to document requests for screening or the assistance provided
clients in obtaining this or diagnosis and treatment within a
specified time frame as required by regulation; and, the States'
inability to mandate program participation and uniform reporting
for private practitioners and the voluntary clinics per visit
rates." 13
Local project opinion was then directly considered:
"We have reviewed the letter submitted by Mr. 3ryant and
regret the delay in replying. We agree with Mr. Bryant's opinion
the Department of Public Aid has not evidenced sufficient interest
in this project or established the working relationship necessary
for its finding to have impact on the State's program operation.
This has been discussed with the State EPSDT Coordinator who re-
ported that the major problems stemmed from two factors;
1. limitation of staff at state level and, 2. problems with the
administration of the public assistance program in Will County.
Because of the latter problem the previous county superintendent
has been removed."
"We likewise concur with the observation that the Medichek
program in Illinois has not been handled as a priority program.
Until this is changed, we share Mr. Bryant's pessimism about the
possible accomplishments of the project in assisting the State to
develop effective implementation of a meaningful EPS DT program in
Illinois. We believe that our Quarterly EPSDT Penalty Reports and
recent Program Analysis Report substantiate this fact."
"Mr. Bryant is also correct in his statements regarding the
sporadic contacts between project staff and the Regional Office
and the fact that HEW emphasis has been on monitoring penalty
compliance. We have tried, however, to maintain open lines of
communication with the Will-Grundy project. However, due to other
work pressures and changes in assignments within Medical Services,
we have been unable to work as closely with the project and the
State agency as desired, necessary and originally planned. Hope-
fully,this can be accomplished in the near future." I4
It should be noted that these communications reached the local
project indirectly and several months after transmittal The direct
contact between the Region V office and the local project never
material i z ed .
The locally perceived apathy to the development of EPSDT on
the local level on the part of the State of Illinois and the
Department of Health, Education and Welfare was again summarized
at the conclusion of meetings regarding revision of the Medichek
claim form, as described earlier:
"As we near the completion of two years of attempting to im-
plement the delivery of Medichek services in private office settings
we are forced to the obvious conclusion that neither the Illinois
Department of Public Health nor the Department of Public Aid have
any real interest in Medichek or in working cooperatively with the
medical community. Major problems in the Medichek program, ident-
ified initially in 1974, remain unchanged. It is our opinion that
these problems will remain unchanged until a more powerful entity
than organized medicine forces a change." 15
Clyde V. Downing, Memorandum to Dr. Keith Weikel , Commissioner,
Medical Services Administration, dated December 16, 1975.
Ronald Bryant, letter to Larry Boress, Illinois State Medical
Society, dated Atril 21, 1976.
(2 5)
The lack of response to this project by the Illinois Depart-
ment of Public Aid and Illinois Department of Public Health is
not surprising when viewed against the climate surrounding the public
aid system during the contract year. The entire public aid program
has been embroiled in controversy since the onset of the local
project in July, 1975. The Medicaid program in particular has been
repeatedly wracked by scandal centering on program abuses by
various categories of providers. The United States Attorney in
Chicago has publicly referred to Medicaid abuses as one of the most
serious law enforcement problems faced by his office. Concurrent
state and federal investigations of the Medicaid program are
continuing .
An attitude of def ensiveness and mistrust on the parts of state
officials and providers, engendered by the continuing investigations
and public reaction to them, has been further aggravated by a de-
teriorating relationship between the Illinois Department of Public
Aid and the Illinois State Medical Society. The decline in this
relationship was heightened following testimony by the president
of the Illinois State Medical Society to the Legislative Advisory
Committee on Public Aid in October 1975:
"In the past, the Illinois State Medical Society strongly
encouraged its members to participate in this program. As a result
more than 3,000 physicians are now treating Medicaid patients in
Illinois. However .... in view of IDPA's recent irresponsible ad-
ministrative directives and proposed cuts in reimbursement levels
....we cannot in good conscience continue to urge participation.
"Perhaps the only solution is to remove administration of
Medicaid from the Illinois Department of Public Aid and place it
in an area where it can be administered responsibly .... and with
emphasis on the quality of care."
"The Illinois State Medical Society acknowledges that re-
sponsibility for assuring quality care under Medicaid is shared
by government and the medical pro f e s s ion . . . . al 1 we ask is that we
be given the opportunity to share in that responsibility."
°J. M. Ingalls, M.D., President, Illinois State Medical Society,
testimony to the Legislative Advisory Committee on Public Aid,
October 16, 1975.
(26)
These statements were followed, in November, 1975, by approval of
a resolution by the House of Delegates of the Illinois State
Medical Society, reading in part;
"RESOLVED, that the Illinois State Medical Society affirm the
policy that withdrawal of individual ISMS members
from the Medicaid and Medichek programs will not
be considered unethical, unprofessional or dis-
ho nest." 1 '
It was against this background that the local project was attempt-
ing to establish a working relationship with the Illinois Depart-
ment of Public Aid and Illinois Department of Public Health to
assist with local implementation of the Medichek program.
At the local level, project staff has been faced with con-
tinual withdrawal of physician participation in the Medichek pro-
ject as a result of the general climate already noted and the
specific failure of the project to resolve long identified problems.
The growing frustration, particularly among primary care phy-
sicians, was best summarized in the annual report to the Board of
Directors by George E. Hord, M.D., Chairman, Public Health and
Medical Services Committee:
"I doubt that any undertaking of this Society has so tested
the frustration tolerance of those involved. Details of most of
the problems encountered have been elucidated by Doctor Albert
Ray in his November appearance before the Illinois Legislative
Advisory Committee on Public Aid....
"However, more important than any of these enumerated prob-
lems are the attitudes toward Medichek. The Illinois Department
of Public Aid views it as a bastard child dumped on its doorstep
and gives it minimal attention. Legislators are poorly informed
and perplexed by the commotion. Most physicians see it as another
bureaucratic infliction upon them. The public remains apathetic.
"Our official involvement in the Medichek Project ends
July 1, 1976. Despite the difficulties, we are continuing to do
what we can ... .
"In the past eighteen months, we have seen only token and
superficial changes made in Medichek. Unless dramatic revisions
are soon forthcoming, Medichek is doomed to an agonal demise.
May it rest in peace and may we choose our windmills more care-
fully in the future." *-8
i -j
Resolution 7 5 N - 2 5 , HO use of Delegates, Illinois State Medical
Society, Adopted November 12, 1975.
EPSDT/Medichek , 1975 Year End Report, George E. Hord, M.D.,
presented to the 3oard of Directors of the Will-Grundy County
Medical Society, January 11, 1976.
This summation was supported by a report to the Will-Grundy County
Medical Society Board of Directors, documenting the investment of
over 330 physician hours in the project operation between July 1,
1975 and December 31, 1975. Local physician frustration with the
Medicaid system was sharply illustrated again in April, 1976, with
the decision of a large mu 1 1 i - spec ial ty group in Joiiet providing
medical care to approximately one-half the Medicaid-eligible fam-
ilies in Will County, to terminate services. That decision was
withdrawn but the group remains opposed to continued long range
participation in the Medicaid program.
What, then, have we learned through discussions with state
and national leaders concerning implementation of SPSDT at a local
level? Our findings can be briefly summarized:
A. The problems initially identified in 1974 in "A Report on
Professional Health Provider Participation, EPSDT/Medichek ,
and restated in Professional Health Provider Participation,
EPSDT/Medicaid , our 1974-75 final report, remain virtually
unchanged. The slowly and carefully developed recommendations
for solutions of these problems remain unconsidered and un-
implemented. Local project attempts to open channels of
communication for cooperative discussion of these problems
for a period of two years were greeted with apathy and dis-
regard .
3. A county medical society alone is unable to overcome the
dynamics of larger events which contribute to a deterior-
ating relationship between organized medicine and state
government to accomplish the goals of a local project.
These events, and the general climate in which this project
was conducted, effectively prevented the Will-Grundy County
Medical Society from having a significant impact on implement-
ation of delivery of the EPSDT program.
(23)
COMMUNITY HEALTH SERVICES PROGRAM
The Community Health Services Program was originated from
the findings of the 1974-75 sub-contract period. The impetus for
the inclusion of the program into the present contract was the
cancellation of the Society's physician rotation program. As a
result of that cancellation, the Executive Committee of the Society
authorized the immediate investigation into developing an altern-
ative delivery system. That directive was refined in the proposal
to develop the 1975-76 contract:
"....it was recognized that the private practitioner could
not handle EPSDT needs alone and that the professional community
must take a leadership role in developing accessibility to the
health care systems even to the point of encouraging non-
traditional methods of delivery of health care services. The con-
tractor intends to find or develop the needed alternatives." 19
A further refinement of the concept is mandated in the contract:
"3. Development of a plan to provide a Community Health
Services Program. This plan would address the following
issues :
A. Ability to utilize related health professionals in the
delivery of primary care services.
B. Methodology for the delivery of coordinated community
health welfare and social services by taking those services,
where practical, to the target population.
C. Recruitment, and potential employment of physicians to work
in the Program.
D. Removal of historical barriers to accessibility to care caused
by inadequate numbers of primary health care providers. 20
Request for Non-Competitive Procurement, Helen S. Martz, Ph.D,
dated May 7, 197 5.
20.
Scope of Work, Contract SR3 300-75-0030, date;
un
30,
1 9 7 5
(29)
The planning structure to implement the contract mandate
was in place, in the form of the Community Steering Committee,
prior to the beginning of the contract. The Committee included:
Executive Director - Will County Health Department
Executive Director - Joliet-Will County Community Action Agency
Executive Director - Will, Grundy, Kankakee Comprehensive
Health Planning Council
Supervisor - Will County Department of Public Aid
Administrator - Silver Cross Hospital
Administrator - Saint Joseph Hospital
President - Will-Grundy County Medical Society
The Community Steering Committee was an ad hoc group initially
formed to deal with the effect of the cancellation of the Society's
patient-physician rotation assignment program and the problems
caused by the resulting increase in patient load in hospital
emergency facilities. The group conducted several informal discus-
sions prior to initiation of the 1975-76 contract period without
formalizing its structure, defining its role or establishing
definite goals. Since the group contained all of the community
elements which would have been gathered to address this phase of the
contract, it was continued as a committee. Input from the Society
was arranged through creation of an ad hoc committee of eight
physicians under the direction of the chairman of the Public Health
and Medical Services Committee. Five of the physicians were mem-
bers of that standing committee, three were drawn from the general
membership of the Society.
The organization of the Community Steering Committee and the
ad hoc committees was informal and there was no specific under-
standing of the role of each in relation to the other in develop-
ment of the program. The only link was the presence of project
staff. Members of the Community Steering Committee were initially
unaware of the commitment of the Society to the contract. Although
members of the ad hoc committee were aware of the responsibilities
of the contract, they defined their role as limited to providing
medical advice to plans developed by the Steering Committee and
viewed their function as self -liquidating by January 1, 1976. It
was the general understanding of the Ad Hoc Committee that develop-
ment of the program requiring their input would be completed by
that date.
(30)
Again the discontinuity between contract periods at a local
staff level caused confusion in the direction of the program.
Although the Community Steering Committee had been meeting for
nearly three months prior to implementation of the contract there
were no records of the activities of the group. The Committee had
no formal leadership until immediately prior to implementation of
the contract when the Executive Director of the Will County Health
Department assumed that function. Through a series of individual
interviews with members of the Committee, project staff was made
aware of a series of very general decisions made prior to the
beginning of the contract period concerning the creation and op-
eration of a community health center. The Community Steering Com-
mittee had accepted the concept of a health access station to be
centrally located in the city of Joliet to provide services to a
target population roughly defined as the poor, elderly, public aid
recipients and those in need of service who were not on public aid
but unable to pay for services. There was no clear definition of
what those services would be. Members of the Community Steering
Committee favored creation of a separate legal entity to assume
responsibility for operation of the health access station but had
not determined the nature of that entity or who would be involved
in it. Some committee members were concerned about the possibility
of conflicts of interest, duplication of services or competition
developing between the health access station and other community
organizations providing social and welfare services to the same
broadly defined target population.
In order to formalize the planning process, project staff
developed and presented to the Community Steering and Ad Hoc
Committees a timetable of activities based on the schedule of
anticipated activities included in the contract. This timetable
reflected the original commitment of the contract to complete
planning of the Community Health Services program by January 1,
1976. Areas of responsibility between the Community Steering
Committee and the Ad Hoc Committee of the Society were defined
as follows :
Steering Committee Discussions.
1. Identification of basic community resources.
2. Development of methodology for gaining access to resources
3. Development of specific materials reflecting methods of
gaining access to community services.
4. Development of svstem to coordinate health welfare and
(31)
3. Ad Hoc Committee - Will-Grundy County Medical Society.
1. Development of plan to evaluate the quality of services
related to the Community Health Services Program.
2. Consultation with the American Medical Association relating
to the technical aspects of the EPSDT programs and the
Community Health Services Project.
Other features of the planning timetable related to contact with
community agencies outside the Steering Committee, the type of
service agreements necessary, a determination of the possible patient
load, the type of legal entity to assume responsibility, scope of
services to be offered, identification of potential local, federal
and private funding sources and development of a draft model.
Recognizing that a major problem area is the growing shortage
of primary care physicians in Will County, the two committees in-
dependently authorized development of an application to the National
Health Service Corps seeking designation of Will County as a critical
medical shortage area and requesting assignment of a physician.
A preliminary application was developed and submitted to the Bureau
of Health Manpower on July 18, 1975 and was refined and resubmitted
on July 30, 1975. The application was denied in September, 1975.
The denial was viewed by the two committees as a setback to the
project since the application had been regarded as one tool for
physician recruitment for the health access station.
Basic weaknesses in the involvement cf two independent com-
mittees appeared rapidly. An obvious weakness was in the exist-
ance of the committees as separate entities with neither assuming
overall responsibility of project planning, but with both assuming
equal authority. This placed project staff in the position of
attempting to obtain dual authorization for any action and comp-
licated coordination of overlapping areas. For example, both
committtees requested cost estimates on the operation of the
health access station but neither could arrive at specific des-
criptions of the station on which to base the estimates. It was
impossible to develop this information accurately without first
defining the scope of services to be offered. Development of
that information with the separate assistance of each committee
required more than a month. During that time, project staff re-
mained the only link between the committees. An attempt was made
to correct the weakness by installing the chairman of the ad hoc
committee as a member of the Community Steering Committee. This,
however, served to confuse the members of the ad hoc committee on
their role in the project and their responsibilities.
Proposed Timetabla Community Health Services Project, Will-Grundy
County Medical Society 5R3 Project, Monthly and Progress Report
July, 1975.
(3 2)
The confusion was compounded by a reluctance on the part of
individual members of the Community Steering Committee to make
any firm commitments in behalf of their respective agencies and
their reluctance to design or serve as part of the legal entity
which would assume control of the project on a long term basis.
Following a series of meetings with staff of the Department
of Rural and Community Health of the American Medical Association
in August, 1375, local staff developed recommendations to clarify
the planning structure. Although it was felt the agencies re-
presented in the Community Steering Committee should remain in-
volved in the project, local project staff recommended increasing
membership on the committee to include persons at a decision-making
level from each agency. It was further recommended that represent-
ation on the Community Steering Committee be broadened to include
other segments of the community, specifically the business, indus-
trial and educational communities. With the committee thus re-
organized and expanded, project staff recommended dividing the
responsibility in a specific area. Finally, local staff suggested
a re-examination of the concept of the health access station as
previously accepted by the Community Steering Committee in light of
the time remaining to complete the project. American Medical
Association consultants also expressed concern at the decision of
the Society's Ad Hoc Committee to phase out as of January 1, 1976
since it was becoming apparent that because of the slowness in
planning, the project would not be completed by that time.
It should be noted that the slow pace of the project during
July, August and September, 1975, was due in part to the increasing
diversion of local staff time to resolving cash flow problems
developing as a result of the payment mechanism described earlier
in this report. The amount of staff time absorbed in attempting
to resolve the payment mechanism with the Department of Health,
Education and Welfare increased with the degree of severity of
the problem. By the end of September, 1975, the cash flow sit-
uation had deteriorated to the point where the continued operation
of the contract and employment of the staff was in danger.
A re-evaluation of the project during September, 1975 ident-
ified and isolated four planning weaknesses which inhibited de-
velopment of the health access station as concieved by the Ste-
ering Committee:
1. "Lack of specific documented need.
This became apparent when attempts were begun to reasonably
estimate the number of persons who would use the services
cf the health access station. The experiences of the
Medi:al Society in the FFSDT demons traticn project, the
Physician ".oiation program and the School Screening project,
while these experiences indicated a need in the community for
development of' an alternative system, they did not specifically
define that need. The concept of a large, centrally located
facility is untenable on this basis.
2. Lack of broad-based community involvement in planning.
Many segments of the community, most notably consumers,
remain absent from this planning effort. The lack of in-
volvement of the business, non-medical professional and
educational sectors demonstrates the restricted nature of
this planning effort to date. While tentative attempts to
involve some of these components were not successful, it is
obvious that the involvement and commitment of these segments
of the community are essential to the success of the project.
3. Duplication of services in the low income population.
This relates directly to the development of a clinic serving
low income persons in Joliet and will be discussed later in
this report.
4. Failure to specifically define area to be served.
Although planning in this project was being done on the basis
of serving the entire population of Will County Illinois, it
became obvious that the service area under consideration in-
volved only a small portion of the county. We found the
Community Steering Committee had not admitted that a small
area was involved but they really had not defined even that
area. The service area was being vaguely described as the
greater Joliet metropolitan area". 22
To address these weaknesses, the Steering Committee adopted
a program planning outline and approved the development of a
physician survey in cooperation with the Will, Grundy, Kankakee
Comprehensive Health Planning Council to provide an indicator of
physician perceptions of delivery problems. In addition, the
Will, Grundy, Kankakee Comprehensive Health Planning Council,
a designated 314 (b) agency under the Public Health Service
Act, was asked to serve as a resource for the demographic data
needed to reasonably project community need for the services of
the project.
[34)
In adopting the following program planning outline, the
Steering Committee agreed that the outline would serve as the
outline for development of a project model:
"PROGRAM PLANNING OUTLINE
I. PROGRAM OBJECTIVES
A. Provision of high quality comprehensive medical and related
health servces which are economically available and acces-
sible to residents of Will and Grundy Counties.
B. Provision of high quality comprehensive medical and related
health services which are economically available and acces-
sible to residents of Will County.
II. ALTERNATIVES
A. Permanent community facility with full time staff
B. Temporary facilities located throughout community with a
rotating health care team
C. Mobile health unit or units with full time staff
D. Permanent community facility with full time staff using
mobile unit or units with rotating health teams
III. ALTERNATIVE CRITERIA
A. Are sufficient resources available or obtainable?
B. What will be the cost for services?
C. Will the alternative improve the overall health of the
community?
D. Time estimated to complete the alternative?
E. What organizational structure is required?
F. Can the alternative be coordinated with on-going fun-
ctions and programs?
G. Will the alternative be acceptable to the professional
and to the consumer?
(35)
IV. SELECTION OF ALTERNATIVE
A. 3ased on which alternative meets the majority of
criteria while meeting needs of community.
V. COMMUNITY NEED
A. Physician Survey
3. Consumer Health Survey
VI. ORGANIZATIONAL APPROACH
A. Community Health Services Council
1. Health Services Providers and Educational Institutions
2. Community Groups and Individuals
a. Industry
b . Bus ine s s
c. Non-health Professionals
d. Civic Groups
e. Educational Leaders
f . Local Government Officials
3. Consumers of Health Services
a. Educational level
b. Family Income
c . Ethnic
d. Age group
f. Vocational representation
4. Size of Council
(36)
5. Function
a . Sat general policy
b. Develop constitution and by-laws
c. Decision making
d. Selecting consultants or enlisting aid of specified
sub- committees
e. Serve as requesting agency for outside financial aid
f. Coordination with overall community planning efforts
. . . 2 3
g. Inform the community or activities
During the period of September and October, 1975, the focus
of both the Community Steering Committee and the ad hoc committee
of the Society was diverted from planning by the implantation of
a new medical clinic in Joliet. Since the new clinic was located
in the same general area under consideration for the health access
station and was attempting to provide medical care to the same
target population, both committees questioned the need to continue
with the project. Instead, contact was initiated with the admin-
istrators of the new clinic to explore the possibility of developing
a contractual arrangement with the clinic for primary services with
the two project committees assuming responsibility for development
of the related social and welfare services. This approach was dis-
continued when information developed by the Community Steering Com-
mittee under the program planning outline indicated the new clinic
alone could not satisfy projected need and the ad hoc committee of
the Society was unable to resolve questions concerning the organi-
zation and operation of the clinic and the quality of care delivered
The decision to discontinue negotiations with the clinic
was based in part on the findings of a special data sub-committee
of the Steering Committee which was charged with the task of
addressing the lack of specific documented need. With staff
assistance frcm the Will, Grundy, Kankakee Comprehensive Health
Planning Council, the sub-committee was able to assist the Steering
Committee in determining the primary service area for the project
as four urbanized townships in the northwest quadrant of Will County
(37)
Ac the same time, the Steering Committee adopted an outline for
pro i ect model :
"COMMUNITY HEALTH SERVICES MODEL
PLANNING OUTLINE
I. PROBLEM DEFINITION
III. GOAL STATEMENT
III. COMMUNITY NEEDS
IV. ALTERNATIVES
A. Cost
3 . Location
C. Manpower
V. DEVELOPMENT OF COMMUNITY HEALTH COUNCIL
VI. DEVELOPMENT OF COMMUNITY HEALTH PROGRAM
A. Implementation
3 . Operation
VII. PROGRAM EVALUATION 24
The Steering Committee also approved a staff timetable for de-
velopment of the actual model specifying presentation and re-
view of all outline steps except Step IV by mid -No vember , 1975,
presentation and review of Step IV in early December, 1975 and
completion and submission of the project model at the end of
December , 197 5.
The Project model, excluding Step IV was completed and
accepted by the Steering Committee. A copy of the model was sub-
mitted as Attachment A to our November, 1975, Progress Report and
is included as Exhibit I to this report. The development and
adoption of the project model served to resolve the earlier
identified planning weaknesses in the Community Health Services
program and also provided a frame work of specified activities
to allow the Community Steering Committee to proceed with the
project. Throughout the period of identification of weakness,
"^Will-Grundy County Medical Society 3RS P r o j ac r -Mc n thly
Progress Report, October, 1975.
(38)
re-evaluation and development of the project model, the support
and assistance of staff of the Department of Rural and Community
Health of the American Medical Association was invaluable. The
American Medical Association provided technical reference
materials and advice to local project staff through each stage
of development of the model.
Several factors contributed to the extremely slow pace of
development and completion of the project model. Throughout the
period of July to December, 1975, the organization of the Com-
munity Steering Committee remained loose and informal. It was
difficult to assemble the Committee more than once or twice per
month and attendance at Committee meetings was sporadic. The
Committee also demonstrated a reluctance to make formal decisions
on various staff recommendations often creating an atmosphere of
confusion about the status of the project at various times. This
general lack of direction was further complicated by the continued
existance of the dual committee structure. Despite attempts to
draw the Community Steering Committee and the Ad Hoc Committee
of the Society together, the groups remained independent. The
necessary re-evaluation of the project which led to development
of the project model removed emphasis from the role of the Ad Hoc
Committee which had responsibility for medical input to the pro-
ject. Although it became apparent that the project would not be
completed in the original six month time frame, the Ad Hoc Com-
mittee did not change its resolution to dissolve as of January 1,
1976. Active participation by physicians on the Ad Hoc Committee
through the period of July to December 1975, was sporadic limited
basically to the specialist members of the committee. These
specialists also served on the Community Steering Committee but
there was little interaction between the groups. Some of these
difficulties were summarized in a report to the Board of Directors
of the Society in January, 1976:
"The concept of a Community Health Services project grew out
of the failure of our rotation system to fulfill the medical needs
of those in this community without a physician. A Community
Steering Committee was formed and expected to develop the project
model with the necessary medical input being supplied by this Ad
Hoc Committee of the Medical Society. Unfortunately, the Steering
Committee was reluctant in making firm commitments and slow in
formulating any sort of plan. Consequently, with a looming con-
tract deadline, the responsibility of model development fell on
(project staff) and the Ad Hoc Committee. This monumental task
was made even more difficult because anticipated technical assist-
ance from CHP and DHEW has been lacking. Even the Ad Hoc Commit-
tee itself has been difficult to assemble and certain committee
members vet to be seen."
(29)
"Soon we must present this finalized package to -he Medical
Society for approval or revision. It can then be presented to
the Community Steering Committee (or Board of Directors) to put
into action. We will meet our contract deadline. However, based
on the early inertia of the Community Steering Committee, I remain
somewhat skeptical about the implementation of this model. It
will necessitate full cooperation of many agencies, and based on
earlier reluctance, it may not be forthcoming. As a Society, we
cannot, and should not even attempt to, implement this project
alone." 2 5
The development of the project model and its implementation
by the Community Steering Committee was also seriously hampered
by the loss of members from the Committee. Since each member of
the Committee represented a segment of the community vitally im-
portant to the project, the departure of any member diminished the
capability of the Committee. Between July and December, 1975, the
Committee lost the participation of the Will County Department of
Public Aid and the Will, Grundy, Kankakee Comprehensive Health
Planning Council.
Representation of the Will County Department of Public Aid
was lost with the transfer of the local supervisor to another
post. The position was left unfilled by the Illinois Department
of Public Aid for several months. When a new supervisor was
appointed, he did not respond to invitations to j o in . the . Communi ty
Steering Committee. The loss of the only link between the project
and the public aid system deprived the Community Steering Committe
of needed input relating to problems of the majority of the target
population .
The loss also terminated the development of a mechanism to
include EPSDT services in the project model or to explore means
of removing administrative roadblocks, identified earlier in this
report in the implementation of the project model.
Community Health Services Project, Year End Report, George E.
Hord, M.D., presented to 3oard of Directors, Will-Grundy County
Medical Society, January 11, 1976.
(40)
The active involvement of the Will, Grundy, Kankakee
Comprehensive Health Planning Council on the Community Steering
Committee ended abruptly in December, 1975, with the dismissal
of the Executive Director of that agency. This action left the
Commmunity Steering Committee without a source of localized
technical information necessary to the development of the project
model. The loss of this agency on the Committee deprived the
Committee of its research arm. The involvement and support of
the Will, Grundy, Kankakee Comprehensive Health Planning Council
had been one of the primary reasons for inclusion of the Community
Health Services Program as part of the Society's contract. With-
out access to the resources of the agency, completion of the
project model, primarily a staff document, was very difficult.
The Community Steering Committee encountered another, un-
anticipated obstruction through Public Law 93-641, the National
Health Resources and Development Act of 1974. The Will, Grundy,
Kankakee Comprehensive Health Planning Council became an applicant
for conditional designation as a Health Systems Agency under the
new planning law. Although the Community Steering Committee was
not aware, staff participation of the agency in the Community
Health Services project was increasingly limited during the period
of September to December, 1975, as the HSA application was developed,
The decreasing availability of assistance from the agency accelerated
following the dismissal of the Executive Director of the agency in
December, 1975. This increasing internal preoccupation with com-
pletion of the HSA application prevented completion of items im-
portant to the Community Health Services project. For example,
in writing the project model, project staff was left with the task
of sorting out a mass of demographic information supplied by the
Will, Grundy, Kankakee Comprehensive Health Planning Council after
much of the data proved to be outdated, unreliable and unrelated.
This task was completed with the assistance of staff members of
the Department of Rural and Community Health of the American Medical
Association. The physician survey, initiated during the re-eval-
uation of the project in September, 1975, although scheduled for
completion within six weeks, was never finished. The reason did
not become apparent for several months:
"Unfortunately, the final report of the Physician Survey,
undertaken by the Comprehensive Health Planning Council will not
be available until March 15, 1976. The reasons for the delay are
twofold: 1) at the onset of the Physician Survey, I was unaware
that I would be assigned, full time, from November 15th to January
19, 1976, to work on the Health Systems Agency Application, and
(41)
2) than our Project Review Officer would resign, causing my
assignment to Project Review."*
As internal problems over staffing and management of the agency
increased during January and February, 1976, work on the physician
survey was not resumed and was dropped following the resignation
of the staff liaison.
Development of the HSA application placed other pressures on
members of the Community Steering Committee which brought im-
plementation of the project model to a virtual halt for several
months. Because of the inter-relationship of the community, all
non-physician members of the Community Steering Committee were
also members of the Board of Directors of the Will, Grundy,
Kankakee Comprehensive Health Planning Council. The time of
these Committee members was increasingly absorbed by problems
surrounding completion of the HSA application and by growing pro-
blems regarding the continuation of the CHP agency itself.
During the period of January to March, 1976, the agency faced
serious internal problems relative to financial management and
staffing. While implementation of the Community Health Services
project lay nearly dormant, Community Steering Committee members
devoted their energies to addressing other problems. These
problems were finally resolved in April, 1976, by the withdrawal
of designation of the Will, Grundy, Kankakee Comprehensive Health
Planning Council as a 314 (b) agency by Region V, Department of
Health, Education and Welfare and the closing of the agency.
The structure of the Community Steering Committee was also
threatened by the opposition of the Society to the HSA application,
spearheaded by physician members of the Committee. This opposition
developed after the Society was asked for a routine endorsement of
the application in December 1975. Project staff was assigned to
review the application which resulted in the opposition of the
Society to several technical components of the application. This
opposition resulted in physician and staff participation in a
series of meetings during December, 1975 and January, 1976,
directed at correcting what the society viewed as gross defic-
iencies in the application. When these meetings failed to resolve
differences over the application, the relationship between the
Ken Marshall, Health Planner, Will, Grundy, Kankakee Compre-
hensive Health Planning Council, Memorandum to R. 3ryant , Will-
Grundy County Medical Society, January 21, 1976.
(42)
Society and the Will, Grundy, Kankakee Comprehensive Health Plan-
ning Council solidified into adversary positions. Under the
pressure of these positions, staff level communication became
strained, then ceased completely. These events, coupled with the
eventual denial of the HSA application and the closing of the Will,
Grundy, Kankakee Comprehensive Health Planning Council, combined
to deprive the Community Health Services project of one of its
most important local sources of support and assistance. The small
momentum of the Community Steering Committee, generated by
completion of the project model in December, 1975, was at first,
disrupted, then halted by the pressure of larger, outside events.
During the period of mid-January, 1976 to late April, 1976,
physician members of the Community Steering Committee attempted
to restart movement in the project by attempting to develop a
firm concept of a feasible alternate delivery system:
"The Ad Hoc Committee of the Will-Grundy County Medical Society
has been considering alternative methods for delivery of primary
care services in the Community Health Services project. The com-
mittee has arrived at what would appear to be a viable means of
providing services but wishes to communicate the options to the
Community Steering Committee prior to inclusion in the project
mode 1 .
Research by the Ad Hoc Committee indicates that the develop-
ment of an independent free-standing clinic may be an unnecessary
duplication of services already available in the four townships
considered the primary service area of the project and assured
continuous funding from any source in the current political climate
seems unlikely. It would seem a more valid approach for the Com-
munity Steering Committee to consider developing appropriate con-
tractual arrangements with several already existing entities to
deliver primary care services. The Ad Hoc Committee has only
recently become aware of the development of facilities within the
community which would allow this approach.
If a contractual approach is acceptable, it would leave the
Community Steering Committee with the responsibility to develop
only a small, reasonably inexpensive administrative facility.
It would be the responsibility of this administrative structure
to negotiate contracts, to register patients and guide them to
appropriate facilities and to provide negotiating services be-
tween the Illinois Department of Public Aid and the participating
facilities. These negotiating services would include prior review
of Medicaid and Medichek bills and the resolution of disputes
between IDPA and participating facilities. Ail payments, however,
would be made directly to the participants. Once this system is
established and operating, efforts can be initiated to develop
ancillary services and transportation services through the ad-
ministrative core.
It is also the opinion of the Ad Hoc Committee that the Com-
munity Steering Committee should carefully consider the potential
impact upon this project of the impending development of a Health
Systems Agency. The Will, Grundy, Kankakee Comprehensive Health
Planning Council has already organized an ambulatory care committee
which has set ambulatory care planning and resources development as
its primary goal. It is reasonable to assume that if the Will,
Grundy, Kankakee Comprehensive Health Planning Council receives
conditional designation as a Health Systems Agency under Public Law
93-641, the function of the ambulatory care committee will be
transferred to the new agency. The nature of PL 93-641 is such
that the Health Systems Agency will have significant authority over
the development of projects such as ours.
Public Law 93-641 specifically provides that each Health
Systems Agency will be generally responsible for preparing and
implementing plans to improve the health of residents of its health
service area; to increase the accessibility, acceptability, con-
tinuity and quality of health services in the area; to restrain
increases in the cost of providing health services; and to prevent
unnecessary duplication of health resources. The law also pro-
vides that Health Systems Agencies will review and approve/disap-
prove applications for federal funds for health programs within the
health service area. It is the opinion of the Ad Hoc Committee
that these are valid issues for the Community Steering Committee
to consider at this time.
It is the suggestion of the Ad Hoc Committee that the Com-
munity Services Committee meet at the earliest possible date to
review these issues relative to Health Systems Agencies and to
consider the alternative for delivery of services broadly outlined
in this letter." ^7
George Hord, M.D., letter to James Barringer, Chairman, Community
Steering Committee, January 14, 1976.
(44)
The impetus for this suggestion was the development of an
informal outpatient clinic by a private group of physicians under
contract to provide emergency room services at Silver Cross Hospital
in Joliet. The suggestion was also a restatement of the Society's
concern to utilize existing facilities in the community rather than
impose new duplicative facilities. This concern had first been
expressed in October, 1975, in attempts to develop a contractual
arrangement with the clinic described earlier in this report
Although the Community Steering Committee met to consider
the suggestion and authorized project staff to develop a model
contract, the effort was forestalled by the controversy surround-
ing the Health Systems Agency application and other internal problems
of the Will, Grundy, Kankakee Comprehensive Health Planning Council
to which the Community Steering Committee was tied.
Two events in April, 1976, caused the rebirth of the Community
Health Services project. The first was the release of $30,000 in
federal revenue sharing funds by the City of Joliet to the Joliet-
Will County Community Action Agency for use in the project. The
funds had been placed in escrow in December, 1975, following a
preliminary review of the project model. The second event was a
reaction to mounting physician frustration with the Illinois De-
partment of Public Aid with the tentative decision of a large
multi-specialty group to discontinue participation in the Medicaid
program. That tentative decision raised the possiblity that ap-
proximately 45% of the Medicaid patients in Will County could be
without direct access to medical care except through hospital
emergency rooms. Meeting to consider these developments, the
Community Steering Committee arrived at a number of important
decisions, some long overdue.
Members of the Committee are formalizing their commitment to
the expansion of primary care services through incorporation of
a non-profit legal entity tentatively named Will County Health
Care Incorporated. Members of the initial Board of Directors are:
Albert W. Ray, Jr., M.D., Will-Grundy County Medical Society
Guy A. Pandola, M.D., Will-Grundy County Medical Society
George Z. Hord, M.D., Will-Grundy County Medical Society
James 3arringer, Will County Health Department
Keyton Nixon, Administrator, Silver Cross Hospital
Robert Schinderle, Administrator, Saint Joseph Hospital
Doris Dalton, Executive Director, Joliet-Will County Community
Action Agency.
The legal mechanics of incorporation under the Illinois General
Not For Profit Corporation Act are underway at the writing of
this report. The new Board has decided to implement the broader
involvement of the community as described in the project model
upon completion of formal organization of the corporation. The
project model itself has been adopted as a general guide for the
organization .
The new 3oard has also voted to pursue development of
alternative delivery mechanisms beyond the expiration of the
subject contract with a target date of becoming operational as of
January 1, 1977. Staff support in these efforts will continue
from the Society.
The new Board has begun investigation of private funding
sources for development of new ambulatory care mechanisms. Pre-
liminary applications for funding have been prepared for the Mobil
Foundation of Mobil Oil Company and for the Hospital Research and
Educational Trust of the W. K. Kellogg Foundation. Copies of
these preliminary documents are included as Appendix II to this
report. A response to these applications has not been recsived
at the writing of this report.
In summary, the Community Health Services project must be
viewed as a qualified success. The project was initiated in con-
fusion over the roles of its various components, its goals, its
direction and the relationship and responsibilities of its par-
ticipants to this contract. Much of this confusion can be at-
tributed to the discontinuity between contract periods and changes
in local project staff as discussed earlier in this report. The
project survived a searching re-evaluation of its structure and
necessity and succeeded in development of a model with the po-
tential of expansion into an alternative delivery system. It will
be possible within that structure to design a mechanism for con-
tinued delivery of EPSDT services and to explore the development
of an ambulatory care review system as a method of evaluation of
the projects' services to its target population.
The decision of members of the health care community to
the project was demonstrated by their withstanding of unforeseeable
events and by continuance of the project despite the loss of
several important components. The loss of these components, par-
ticularly of the Will, Grundy, Kankakee Comprehensive Health
Planning Council, contributed to the slow progress which character-
ized the project. Despite the setbacks, there was progress through-
out the project and majority, if not all, of the objectives of the
project were accomplished orior to the end of the contract.
(45)
SCHOOL SCREENING PROGRAM
The 1976 School Screening Program was a major component of
contract SRS 500-75-0030 as mandated in Exhibit A of the scope
of work of the contract. The exhibit consists of an outline
prepared following evaluation of the school screening program
under the 1975 sub-contract as an attempt to develop a more
adequate mechanism for mass screenings. The outline provided
specific guidelines to elevate the qualtity of physical asses-
sments performed in a mass setting:
MECHANICS
To facilitate handling large numbers of students the scre-
ening could be broken down into three phases; pre-screening ,
screening and evaluation.
1. Pre-screening; this phase of the program would include
medical history taken by qualified volunteers, immunization
history, developmental history, psychologic evaluation,
T.B. testing, urine and hemoglobin testing and statistical
data collection.
2. Screening
a. General Physical
b. Special Neurologic
c. T.B. Test Reading
d. Dental examination-at the discretion of the Dental Society
3. Evaluation: This phase could take place shortly after the
screening with staffing by teachers, psychologists, social
workers and physicians reviewing the information gathered
and the following dispositions made:
a. Medical problems referred for diagnosis and treatment.
b. Dental referral for corrective work.
c. High risk educational problems directed toward immediate
placement in individualized remedial programs after more
extensive testing.
(4?;
d. Low risk problems directed toward regular classroom
activity but under close observation." *°
In addition, the pr e-scr eening portion of the outline contained
seven specific recommendations to implement the generalized con-
cepts included in the introductory statement. The approach was
designed to provide the physician with the most complete infor-
mation available on aach child participating in a mass screening
examination. The task of the project staff was to define and
develop the specific activities to implement the outline through
available resources in the community.
The organization vehicle chosen to implement the 1976 School
Screening Program was the School Health Advisory Council. Composed
of representatives of the Will County Health Department, the
Joliet-Will County Community Action Agency, school nurses from
Joliet Grade School District 86, the office of the Will County
Educational Service Region and the Medical Society, the Council
was formally organized from the committee which planned and directed
the 1975 school screening program. Although a new organization
in its formal state, the Council was experienced in the program
and incorporated the elements necessary to implement the mandated
outline of the 1976 program.
The point of departure for the program was identical to the
1975 program; a requirement by the State of Illinois that children
entering kindergarten, 5th grade and 9th grade complete a physical
examination prior to the beginning of the school year. Each year
the schools are faced with the problem of indigent families who
do not complete the required examinations, because of financial
difficulties, the family does not have a regular physician, or
through parental apathy. While state law requires that children
who do not complete the examinations be excluded from classes,
the schools are reluctant to take that step. Thus, the school
screening program provided an opportunity for the schools to re-
solve a continuing problem while providing the Society with an
opportunity to identify Medichek-eligibles and enroll them in the
program .
Exhibit A-Contract SRS , 5 0 0-7 5 -0 0 3 0 -Depar tmen t of Health,
Education and Welfare-June 30, 1975.
(48)
In December, 1975, the model outline was presented to and
adopted in principle by the School Health Advisory Council. A
target date of early April, 1975, was approved for the mass
screening clinic to allow rime to develop and complete the neces-
sary pre- screening activities. The Will County Educational
Service Region was requested to provide a list of children who had
not completed physicial examinations from each school district in
the county. It should be noted that this list did not identify
Medichek-eligible children due no the restrictive problem of
confidentiality. The single eligibility criteria was the absence
of a completed physical examination at the required grade level
and financial inability of the family to obtain the examination
privately. As indicated from previous experience, the majority
of eligible children were students of Joliet Grade School District
86. 3y the end of January, 1976, a total of 613 eligible children
were identified by Joliet Grade School District 86 was an estimated
200 eligible children were located in other school districts of
Will County.
To accomplish the pre-screening phase of the model outline,
the School Health Advisory Council approved a two step program
in January, 1976:
Outr each-Thi s phase involved visits to the homes of eligible
children by volunteer outreach teams. Each team was composed
of a professional outreach worker from the Joliet-Will County
Community Action Agency and student nurses from the St.
Joseph School of Nursing, the School of Nursing of Lewis
University and the School of Nursing of Joliet Junior College.
It was the responsibility of each outreach team to obtain
written parental consent for participation in the program
and to complete a medical history on each eligible child.
Consent forms were developed with staff assistance from the
American Medical Association. Each consent form contained
space to allow parents to identify children as Medichek-
eligible and to authorize completion of a Medichek examination
through the school screening program. Completion of this
section of the form required the outreach teams to present
an explanation of the Medichek program to parents and to
explain their rights of freedom of choice in participating
in the Medichek program. Local project staff assumed the
responsibility to design the appropriate consent form and to
gather and collate other educational materials presented to
parents during the home visits. In addition to patient-
oriented Medichek pamphlets, these materials included infor-
mation from the Will County Health Department on immunization
clinics and Well-Baby Clinics and program materials from the
Joliet-Will County Community Action Actencv.
(49)
Project staff arranged and conducted three training sessions
for the volunteer outreach workers and student nurses involved in
this phase of the program. In addition to informational packets,
these training sessions included detailed discussions of the
legislative and program background in EPSDT, the involvement of
the Will-Grundy County Medical Society in the local demonstration
project and the overall purpose of the school screening program.
Each program was presented with the assistance of a physician and
public health n u r s 6 s of tri e Will County Health Department. The
sessions were conducted at the St. Joseph School of Nursing, for
students of that school and from the School of Nursing at Joliet
Junior College, at the School of Nursing at Lewis University and
at the offices of the Joliet-Will County Community Action Agency.
To facilitate the actual home visits, project staff developed
visiting schedules, grouped appointments by geographical area for
each outreach team, and as much as possible, arranged appointments
in advance with families by telephone. The master list of eligible
children supplied by the schools was used in coordinating this
activity. In addition, project staff met with the outreach teams
each day to review assignments, discuss problems encountered in
day to day activites and to inspect informational packets distrib-
uted to the teams to insure the packets were complete. The medical
histories collected by the outreach teams were reviewed by a
physician to avoid important omissions, whenever possible. Infor-
mation recorded on daily assignment sheets was also recorded on the
master school list for later use in followup visits. All volunteers
were asked to work at least three hours per day and since various
groups of volunteers were available at different times, local pro-
ject staff assumed responsibility to coordinate outreach workers
and student nurses. At the end of each day, the records of Medichek-
eligible children were separated from the overall pool and project
staff completed the necessary reporting forms for the State of
Illinois .
Using this mechanism, visits were completed to the homes of
621 eligible children in six days, from February 9 to 11 and
February 16 to 18. At the end of the second week, outreach teams
made multiple efforts to complete previously unsuccessful home
visits. The public was made aware of the program through infor-
mational releases to local news media prior to the beginning of the
home visits. As an additional service of the program, individual
schools were notified at the end of the first week of the names
of children dropped from the program. This information was also
made available to the office of the Will County Educational Service
Region. As mentioned earlier, all volunteers were asked to work
( 50 ;
at least three hours per day in the outreach phase but in fact,
many worked far beyond that. The actual number of volunteers
was relatively small:
Joliet-Will County Community Action Agency - 21
School of Nursing-Lewis University - 19
St. Joseph School of Nursing - 17
Miscellaneous -10
Pershing School PTA
Will-Grundy County Medical Society Auxiliary
Pediatric nurse practitioner
Friends and family of project staff
In addition, four local business firms and a community agency
donated materials and suppies used in the outreach phase.
In the six days of the outreach phase, medical histories and
parental consent forms were completed on a total of 299 children
eligible to participate in the program. Project staff made random
home visits with the outreach teams. The reception of families
visited was positive and the teams reported no problems. It
should be noted that the outreach phase of the program was charac-
terized by a spirit of cooperation.
b. Pre-screening : The Will County Health Department assumed
responsibility for completion of Phase II, or the pre-
screening portion of the school screening program. Pre-
screening services included TBN testing, urine testing,
blood testing and immunizations. During the month of March,
1976, teams of Joliet school nurses and public health nurses
from the Will County Health Department, accompanied by pro-
ject staff, visited individual schools in Joliet Grade School
District 86. Specimens were analized by the laboratory at
the Will County Health Department, at no cost, and the re-
sults were distributed to schools for attachment to each
child's individual health record. Three days following
administration of the T3Ns , school nurses read the casts
and reported the results on the health records which would
accompany each child to the mass clinic in April. In a
separate, but related program, the Will County Health De-
partment completed dental examinations in the schools and
these results were added to the child's individual health
record. Standing medical orders were prepared by the Will-
(51)
Grundy County Medical Society and distriburad to the necessary
personnel of the Will County Health Department and school nurses
of Joliet Grade School District 86 in advance of the pre-scraening
activities. In this manner, testing and immunizations were pro-
vided to approximately 300 children scheduled to attend the mass
clinic in April.
Since the School Screening Program was offered to all school
districts in Will County, project staff attempted to aileviata
transportation problems for districts in outlying areas by ar-
ranging for examinations in private physicians offices. Since
small numbers of children were involved in each of these districts,
it was not practical to apply the first two phases of the program
in outlying areas. After securing the agreement of physicians
in outlying areas, letters were sent to eligible families advising
them of the arrangements made for their children. Informational
materials from the Will County Health Department, as previously
described, were included with these letters. A total of 35
children were screened in this manner although, since there were
no home visits, there was no way to determine how many were Medi-
chek-eligible .
The program format was altered from the model outline by
the School Health Advisory Council with the deletion of develop-
mental assessments as a component of the screening program. This
decision followed consultation with officials of Joliet Grade
School District 86 who indicated that developmental assessments
were being made through other school programs. In providing this
information to the School Health Advisory Council, the school
district presented a brief explanation of its ongoing programs:
"The Educational Regional Association (S.R.A.) provides
disgnostic and supportive educational services for children ages
0-21. Title VI federal funds are applied for and administered
it
"Among the goals of the Title VI grant, "Child Find" is
emphasized. Two major areas of concern are the 0-3 age group and
the high school dropout. Assessment techniques used to determine
the functional level of the child in the 0-3 age group are the
"Learning Accomplishment File" by Chapel Hill Project and Educ-
ational Profile" by the Peoria Association for Retarded Citizens
0-3 Project. These were compiled from selected materials by
authorities recognized in the field of child development. Por-
tions of the Denver Developmental test are incorporated in the
above tests. After this assessmnet is made, many children ara
(52)
then referred for educational evaluation, speech and language
evaluation and audiology. If further evaluation is indicated,
the child is referred to the nurse to review current physical
appraisal and to obtain a complete medical and developmental
history and to the psychologist for psychological evaluation."
"Preschool screening is available for every child in
District 86 between the ages of 3 and 5. The DIAL screening
device is used as it quickly assesses four areas of developement :
Fine Motor, Gross Meter, Concepts and Speech and Language. Norms
were established on the DIAL Screening device on a large cross
cultured sample .... Children failing the screening are referred
for further diagnostic evaluation for individualized help or
program . "
"Children entering kindergarten or in school who function
below expected achievement, who exhibit lack of perception in
learning concepts, who are withdrawn, or display lack of self-
control are referred to the case action team (psychologist, nurse,
speech therapist and social worker) for appropriate evaluation."
"No children are placed in learning disability, education-
ally handicapped or emotionally disturbed programs without
psychological s . " 29
In mid-March, 1976, the School Health Advisory Council met
to review the results of the Outreach phase of the program and
to finalize plans for the mass screening clinic. Final plans for
clinic routing, transportation schedules, needed voluntary personnel
and equiment as developed by project staff were reviewed and
approved at this meeting. Plans for a final training session for
volunteers were finalized and informational packets prepared.
Instructional materials were developed by the office of the Will
County Educational Service Region and the Director of Nursing at
the Will County Health Department outlining final plans and
responsibilities of participating individual schools. A letter
requesting volunteer support was sent to each member of the Will-
Grundy County Medical Society and a physician schedule was de-
veloped from the responses. Supplies and equipment for the pro-
gram were donated or loaned by St. Joseph Hospital, Silver Cross
Vivian Johnson, R.N., M.S., Teacher-Nurse Consultant, Joliet
Grade School District 86, letter to Guy A. Pandola, M.D.,
dated January 14, 1976.
(53)
Hospital/ St. Joseph School of Nursiig, Professional Medical
Surgical Supply Company and other local businesses. More than
150 volunteers were enlisted for the clinic representing:
School of Nursing - Lewis University
School of Nursing - Joliet Junior College
Will County Dental Society
Will County Dental Society Auxiliary
Will-Grundy County Medical Society
Will-Grundy County Medical Society Auxiliary
Non-project staff -Will-Grundy County Medical Society
Joliet-Will County Community Action Agency
Will County Health Department
Staff members - Quad River Foundation for Medical Care
School Nurses - Joliet Grade School District 86
As can be expected in a mass program of this nature, the actual
operation of the clinic was hampered by unexpected events. For
example, to avoid lengthy delays and congestion at the clinic
site, one of the most serious problems of the 1975 program, the
arrival of buses from Joliet Grade School District 86 was carefully
coordinated to provide a steady flow of children through the clinic.
The arrival schedule was designed to cover most of the children
attending the clinic and was communicated to individual schools
through the District administration which was responsible for trans-
portation. The schedule was interrupted at the beginning when the
first bus was involved in a minor traffic accident enroute to the
clinic site. The problem was compounded when the second arrival
was late. Both buses arrived at the clinic site near midday with
a total of 128 children. With other buses arriving on schedule,
a backlog soon developed in the clinic.
Since the transportation schedule had been carefully arranged,
volunteer time was arranged on the same basis. It was anticipated
that the majority of physical examinations would be completed
during the morning session of the clinic, so the majority of
volunteers were at the clinic site during that time. As a result
(54)
of the breakdown in the arrival schedule, many volunteers had
little to do during the early hours of the clinic. When the
majority of children arrived, many volunteers had departed.
This was particularly critical with physician volunteers since
they were enlisted for specific time periods and many had other
commitments. Most of the physician volunteers had departed when
the majority of children arrived and in addition, several
physicians scheduled in the afternoon hours, failed to appear.
Despite the problems which overloaded the program mechanism, a
total amount of 370 screenings were completed. Approximately 80
children were returned to their school without examinations.
These examinations were completed in a follow-up clinic at a local
grade school during May.
In all, a total of 485 examinations were completed at the
major and follow-up clinics, and through physicians private
offices encompassing all schoool districts in Will County in-
cluding parochial schools. Of these, 174 were identified as
Medichek-eligible , a significant increase over the 1975 program.
Medichek records were completed and forwarded to the Illinois
Department of Public Health for inclusion in the program. Arrange
ments were made for school nurses and public health nurses to
contact the families of children with identified conditions re-
quiring follow-up diagnosis or treatment with individual referrals
to be arranged through the Will-Grundy County Medical Society.
At the close of the demonstration project, no referrals had been
received .
The 1976 School Screening Program was the most valuable,
effective and instructive component of the demonstration project.
The adoption of the model outline, authored from the experiences
of the 1975 program, and the addition of the outreach and ore-
screening phases of the program developed from that outline made
the second program far superior to the original. With the com-
pletion of medical histories and the results of pre-screening
tests available, the physical assessments were more complete and
comprehensive than in the 1975 program. It is our opinion that
the basic mechanism of the program as developed this year is sound
and provides opportunities for further refinement and develop-
ment. The only program element deleted this year was develop-
mental assessment which was disappointing since we regarded it
as an important component of a comprehensive assessment.
The 1976 program again successfully demonstrated the cooperation
and support of many segments of the business and professional
communites and through the outreach phase, provided an educational
opportunity for nursing students not otherwise available to them.
Both St. Joseph School of Nursing and The School of Nursing at
Lewis University have indicated their interest in continuing the
participation of their students in a future program.
A major key to the success of the program is the supportive
involvement and cooperation of local schools which provided a
means to partially overcome the problems of confidentiality in
idenuifing Medichek-eligible children. While this is not the best
answer to the confidentiality problem, it is the best one discovered
in this project. Although a significantly higher number of Medichek-
eligibles were identified in the 1976 program, it is reasonable
to assume that an unknown number of Medichek-eligible children
were not identified if parents chose not to identify them during
the outreach phase of the program. In considering that statement,
it must be remembered that all children who participated in the
program had been previously identified as financially unable to
obtain them privately and it is reasonable to conclude that a
higher number of them were members of recipient families of the
Illinois Department of Public Aid than were identified. This is
a situation which will continue to exist until the overall problem
of confidentiality is resolved at a higher level than this project.
We have learned from the 1976 program that a single mass
screening is not the most efficient means to deliver the services of
the program. The problems of transportation, delays at the clinic
site through overcrowding or delays in clerical work can be expected
to repeat themselves and we must state again the position of the
Society that mass examinations are an undesirable and inefficient
method of preventive health care delivery.
We believe the mechanism can be altered however to eliminate
many of the problems associated with mass screenings. Since a
program of this type would not be possible without the involvement
of the schools, we would suggest developing the program on a con-
tinuing basis throughout the school year. Using the same outreach
and pre-screening technique on a month to month basis, smaller
number of children would be examined at each encounter. This
would eliminate the need for a single mass program and increase
the possibility of completing the examinations in a private
physician's office. We believe this approach would be more accept-
able to individual physicians. Since the schools would be so
closely involved in a continuing program, the adminsistrative
organization of the program should become a responsibility of the
schools at a county level. The role of a medical society should
be advisory since a majority of county medical societies do not
have the staff resources available to effectively organize and
implement a program of this nature. The Will-Grundy County Medical
Society would not have been able to make the 1975 screening pro-
grams available without the resources provided by the Department
of Health, Education and Welfare through the local demonstration
pro j ec t .
Another possibility would be to organize and administer a
continuing screening program through a local community action agency.
As is the case with the schools, adequate staff resources would be
available and both entities can readily identify the target pop-
ulation. A community action agency has the added advantage of
employing professional outreach staff to carry out the first phase
of the program. In either instance, the role of a local medical
society should be limited to providing medical expertise and man-
power and to arranging for physician volunteers to participate in
the program and to utilize existing referral patterns for additional
diagnosis and treatment of identified abnormal findings.
In terms of the overall EPSDT program, the use of school
screenings in any form has two major weaknesses. The program pro-
vides no mechanism for continuing care for the children involved
since the physician performing the screening may not see the
child until the next school-required examination several years
later. This would affect the majority of EPSDT-eligibles in whom
no abnormal conditions are identified. The program also provides
no mechanism to identify and enroll infants and pre-school children
in EPSDT. As operated in the demonstration program, a physician
would not see an EPSDT-eligible child until five years of age
losing the most formative period of the child's life. The obvious
conclusion is that such a weakness does not provide optimum pre-
ventive health care delivery. We can conclude then by saying that
the school screening program did enable us to identify one method
of addressing the problem of confidentiality and to make EPSDT
services available to a larger number of children. While we
believe the program does not provide solutions to many issues, it
is reproducible in other areas. The program does have possibilities
for further refinement and development and if administered by the
agency, the schools or a community action agency with the support
of a local medical society, can make EPSDT services available to
a greater number of children. At the close of the current project,
we can make no statement on the local future of the program.
( 57 }
The school screening program has been conducted for two years
locally using the resources provided under this contract and no
agency has stepped forward to continue the program. We have
advised the School Health Advisory Council that while the Will-
Grundy County Medical Society will not have the resources to
administer another program, we will participate again under the
sponsorship of another agency.
(53)
EPSDT - ONGOING ACTIVITIES
In order to assimilate data from Medichek and Medicaid claim
forms, a record keeping system developed by project staff during
the 1974-75 subcontract period was maintained throughout the 1975-
75 contract period. This system enabled project staff to monitor
the level of delivery of services in private office settings and
provided the additional benefit of a claim review system for
physicians of the Will-Grundy County Medical Society.
Physicians were requested to submit Medichek claim forms to
the project office rather than directly to the Illinois Department
of Public Health for payment. Due to the complicated nature of
the form, a clerical review was completed to correct any errors
or omissions. When errors were located, they were corrected with
the assistance of the submitting office. Two copies were then made
of the form and the original was submitted to the Illinois Depart-
ment of Public Health in Springfield for payment directly to the
provider .
The copies of each form were used to initiate records and
referrals as follows:
a. An abnormal follow-up report was initiated from all claim
forms which identified an abnormal condition requiring
follow-up treatment or referral. The report included the
case name, child's name, case number, child's birthdate,
date of the examination, examining physician and the nature
of the abnormality identified. This information was trans-
mitted to the agency responsible for follow-up, in the pro-
ject area, the Will County Department of Public Aid. The
report contains space for Public Aid personnel to record
case findings during follow-up contacts. A copy of the
report documenting follow-up contact was kept by the Will
County Department of Public Aid and the other was returned
to the project office.
b. In addition, an internal control form was used to document
and control the: a.) age and date of a child's enrollment
in the Medichek program, b.) for use in setting controls
to maintain the program's schedule of visits, and c.) a
family history file copy for use in recording all Medichek
screenings and contacts made by the project with the family.
The enrollment file was checked upon receipt of the claim
form. If the claim form represented an initial screening,
the internal control form was initiated. The enrollment file
was undated icon the completion of each scheduled visit.
This review system was designed to increase the effective-
ness of the local project in several areas. The system attempted
to assist physicians with billing problems and to avoid delays
in payment through errors in claim form completion. Throughout
the duration of this project, delays in payment to physicians was,
and remains a serious and unresolved problem. The prior claim
review system used in the project had no impact on this continuing
source of physician frustration. The use of an abnormal report
form did enable the project office to speed up the referral process
and to prevent children from becoming lost in the bureaucratic
process however the system was adversely effected by the internal
personnel difficulties of the Will County Department of Public Aid
as discussed earlier in this report.
A weakness in the data gathering and control process developed
during the 1975-76 contract period because of the voluntary nature
of the program. When the system was designed, it was based upon
physician participation in the rotation system. Since project staff
coordinated the assignment of patients to physicians under the
rotation program, the system was better able to monitor the number
of visits and track follow-up.
With the cancellation of the physician rotation program late
in the 1975 subcontract period, project staff was removed from
direct participation with physicians and patients. Since project
staff was no longer able to assist patients with scheduling of
appointments, the level of direct contact with patients declined
throughout the 1975-76 period. Without the rotation program,
physician participation in the Medichek project was completely
voluntary and while physicians were encouraged to submit Medichek
claim forms through the project office, and it appears that the
majority did so, there was no established control on which to base
evaluation of data. It cannot then be said that all physicians
participating in the Medichek program utilized the services of
the local project.
The Tables which follow in this report represent the accum-
ulation of data from the system described for the duration of the
project from March, 1974 until June, 1976. It should be noted
that significant trends cannot be identified from the tables. The
figures involved are too small and the time period is not of suf-
ficient length to draw conclusions.
Table I represents the total number of Medichek screenings
by month for the period of March, 1974 to April, 1976, reported
to the project office by submission of claim forms. The Scheduled
Visits column represents the number of screenings performed in
accordance with the mandated schedule of the Illinois Department
of Public Health. The Scheduled Visits are permitted at 5 weeks,
4 months, 6 months, 9 months, 12 months, 18 months, 2 years,
3 years, 4 years, 5 years, 6 years, 10 years, 14 years, and 17
years of age. The column labeled Unscheduled Visits represents
those screenings reported to the project officer performed at other
times than allowed in the Medichek Program. Table II is a break-
down by month and age over the duration of the project.
(61)
TOTAL VISITS 3Y MONTH
TABLE I
SCHEDULED VISITS
UNSCHEDULED VISITS
MARCH 197 4
APRIL 1974
MAY 1974
JUNE 1974
25
33
39
54
0
5
5
6
TOTAL'
156
TOTAL VISITS
172
JULY
1974
68
17
AUGUST
1974
129
15
SEPTEMBER
1974
82
7
OCTOBER
1974
112
12
NOVEMBER
1974
85
25
DECEMBER
1974
49
AVERAGE VISITS
12
JANUARY
1975
81
PER MONTH 96 . 5
8
FEBRUARY
1975
66
3
MARCH
1975
73
9
APRIL
1975
108
3
MAY
1975
36
17
JUNE
1975
114
13
TOTAL -
1058
151
AVERAGE VISITS
PER MONTH 12 . 6
TOTAL VISITS
1209
JULY 1975 38 5
AUGUST 1975 97 10
SEPTEMBER 1975 111 AVERAGE VISITS 16 AVERAGE VISITS
OCTOBER 1975 23 PER MONTH 73.6 50 PER MONTH 10.7
NOVEMBER 197 5 4 5 9
DECEMBER 19" 5 54 5
(62)
TOTAL VISITS BY MONTH
SCHEDULED
VISITS
UNSCHEDULED
JANUARY
1976
41
6
FEBRUARY
1976
19
2
MARCH
1976
9
4
APRIL
1976
174
TOTAL**
736
107
TOTAL VISITS
*If extended for 12 month period the total scheduled visits
would be 468 with 60 unscheduled visits. Since the Will-Grundy
County Medical Society had just begun formal participation in
the Medichek Program, and the Program had received minimal
emphasis among member physicians, the extended figures are
reasonable assumptions of the level of screening for 12 months
without the impact of the local demonstration project.
** Figures for May and June, 1976 not available. Using an
average of 73 scheduled visits per month, the projected total
for the 1975-76 contract period would be S82. Using an average
of 10 unscheduled visits per month the projected total for the
1975-76 contract period would be 137. The projected total visits
would be 1019 for the final contract period.
Some explanatory notes from Table I:
--The total of Scheduled Visits for the months of April, 1975 and
April, 1976 are artificially high because of the number of
Medichek screenings performed in the school screening program
in both years. The majority of screenings in these months fell
into the 5, 5, and 10 year age groups.
--The peak screening months for both contract periods were June,
August, September and October. The higher total screenings of
these months probably reflects the number of school physicals
being performed in private office settings and reported through
the Medichek project office.
--The decline in the average of scheduled visits per month between
the first and second contract periods is the result of a combin-
ation of factors. The return of participation in the Medichek
project to voluntary status following cancellation of the ro-
tation program, the growing frustration of physicians with
bureaucratic difficulties with the Illinois Department of Public
Aid and Illinois Department of Public Health are reflected in
this decline. The sharp decline in screenings, exclusive of
the school screening program in 1976, reflects physician aware-
ness of the impending termination of the local demonstration
pro j ec t .
--Outside the peak months, the variance in monthly totals may be
attributed to periods when the Medichek program received
publicity either publicly or internally in the Will-Grundy
County Medical Society.
--The relatively consistent numbers of screenings throughout the
contract period indicate the local demonstration project did
have an impact on the delivery of EPSDT services in the private
sector. However, the fact that the number of screenings did
not increase through the two year period, in fact declined
slightly suggests the program was maintained more through the
good will toward the Society on the part of individual physicians
than through acceptance of the Medichek program.
(64;
TABLE II
MARCH 1974- JULY 1974- JULY 1975 TOTALS
JUNE 1974 JUNE 1975 JUNE 1976*
6
'Jasks
"1 Q
7 0
4 6
13 5
4
Months
1 8
39
54
161
O
Months
1 4
"7 n
i 9
8 6
17 9
9
Months
1 3
5 a
43
119
12
Months
21
63
42
131
18
Months
3
68
32
103
2
Year
6
61
19
86
3
Year
6
39
28
73
4
Year
9
55
19
83
5
Year
6
65
49
120
6
Year
2
65
12
79
10
Year
10
103
42
155
14
Year
12
34
18
114
17
Year
1
8
5
14
Unscheduled
Visits 16 161 107 284
*Figures from School Screening Program, April, 1975, not availab
for inclusion.
(55)
SOME EXPLANATORY NOTES FROM TA3LE II
The impact of the Society's physician-patient rotation pro-
gram is most clearly illustrated in Table II. The figures in all
age groups are higher during the 1974-75 subcontract period when
the rotation system was in full operation. The figures for the
1375-76 contract period indicate the effect of the cancellation
of the rotation program on the demonstration project.
Table II also would seem to indicate that the EPSDT program
does not reach the top age groups although the project period
was too brief to draw a firm conclusion.
The high number of unscheduled visits (screenings reported
which do not fall within the mandated schedule by the Illinois
Department of Public Health) would seem to indicate a lack of
knowledge of the program on the part of the parents. It should
also be remembered that the figures for the 5, 6, and 10 year
age groups, particularly in the 1974-75 subcontract period are
artificially high due to the school screening program. Figures
from the 1976 school screening program were not available as
records were not returned to the project from the schools in
time for inclusion in this report.
(56)
CONCLUSION
As we reach the conclusion of the EPSDT/Medichek-Community
Health Services project, we do not find ourselves in a position to
make recommendations for development of the EPSDT program. Our
recommendations have been repeatedly made; in Professional Health
Provider Participation, EPSDT-Medicaid 1974-75, in testimony to
the Legislative Advisory Committee on Public Aid of the Illinois
General Assembly and in our monthly reports in the present con-
tract year. We have repeatedly pointed out that there has been
no substantial change in either the problems or the recommend-
ations in the EPSDT-Medichek program since our initial involve-
ment and since our involvement in the 1975-76 demonstration
project was a further attempt to address these issues, we believe
it would serve little purpose to repeat the litany here. We can,
however, make some observations on our experiences.
It has been frustrating and annoying to attempt to meet
the goals of this project while working in good faith against
a background of governmental mistrust and apathy. It is obvious
from our previous documentation that we have been unable to engage
the interest of the Illinois Department of Public Aid or the
Illinois Department of Public Health in addressing matters of
concern to physicians. It is equally obvious that internal staff
problems, at both the regional and central offices of the Depart-
ment of Health, Education and Welfare, severely restricted the
availability of technical assistance to the local project. These
problems, of which we were only indirectly aware, sufficiently
interrupted the free exchange of information to a point where
our project operated in a near vacuum for most of the contract
period .
It is unfortunate that we were forced to lose nearly a
quarter of the contract period resolving administrative difficult-
ies with the payment mechanism which required rearranging the
scope of work of the contract. We accomplished that task while
simultaneously attempting to operate the project however we
believe the difficulties could have been resolved to a much shorter
time had assistance been available.
We would point out that a considerable number of volunteer
physician manpower were provided to this project in administrative
and policy areas. It was our feeling that the project was impor-
tant enough to justify the donation of this time in the beginning.
(57)
A3 our frustration at the lack of program progress and develop-
ment increased, physician involvement was maintained only in
a commitment to discharge an obligation. We are appreciative
of the support of the Will-Grundy County Medical Society in
completing this project under adverse conditions.
We find the outcome of this project both disappointing and
ironic. Having directly initiated development of a Professional
Standards Review Organization and a Health Systems Agency in our
area, and having been successful in both endeavors, we are not
inexperienced in government funded health programs. We did not
find the same level of support and cooperation in the ZPSDT
project as characterised the other projects. The problems en-
countered in the EPSDT project are more puzzling when examined
against the viewpoint of M. Keith Weikel, Ph.D., Commissioner,
Medical Services Administration, in discussion implementation of
EPSDT .
"Together, we have the power to master, rather than be
mastered by, the so-called revolution in health care. The rising
expectations of our people can be met through an exertion of
reason and control. But to do this, we must believe in our powers,
agree among ourselves, and then work together as we have never
done before." 30
M . Keith Weikel, Ph.D., Address to the Annual Meeting of the
American Academy of Pediatrics, Washington D.C., October 22,
ATTACHMENT A
COMMUNITY HEALTH 3EE7TCSS PROGRAM
NOVEMBER, 1975
Prepared by the Will-Grundy County Medical Society and the Will-
Grundy-Kankakee Comprehensive Health Planning Council in cooperation
with:
St. Joseph Hospital
Silver Cross Hospital
Joliet-Will County Conmrunity Action Agency
Will County Department of Public Health
Will County Department of Public Aid
Quad River Poundation for Medical Care
C GMMUNT^Y" STEERING COMMITTEE MEMBERS
1. JAMES BARRTNGER, CHAIRMAN
WILL COUNTY PUBLIC HEALTH DEPARTMENT
2. BORIS B ALTON, EXECUTIVE DIRECTOR
JOLIET-WILL COUNTY COMMUNITY ACTION AGENCY
3. KEYTON NIXON, ADMINISTRATOR
SILVER CROSS HOSPITAL
k. PRANK 0. RANGER, PHD. , EXECUTIVE DIRECTOR
WILL-GRUNDY-KANKAEEE CHP COUNCIL
5. DR. ALBERT RAY, PRESIDENT
WILL-GRTO1DY COUNTY MEDICAL SOCIETY
6. ROBERT SCHINDERLE, ADMINISTRATOR
ST. JOSEPH HOSPITAL
STAFF: RONALD BRYANT, PROJECT DIRECTOR
WILL-GRUNDY COUNTY MEDICAL SOCIETY
KEN MARSHALL, HEALTH PLANNER
WILL-GRUNDY-KANKAKEE CHP COUNCIL
PAGE NUMBERS
INTRODUCTION , 1-3
GOAL STATEMENT h
PROBLEM DEFINITION 5-3
COMMUNITY HEALTH PROGRAM 9-11
ALTERNATIVES
PROGRAM EVALUATION
INTRODUCTION
'■/ill County, one of the most rapidly growing areas in the State of Illinois,
covers SkS square miles in the northeastern section of the state. The county
is within 50 miles of Chicago and is adjacent to the counties of Cook, DuPage,
Kane, Kendall, Grundy and Kankakee in Illinois and Lake County, Indiana. The
population of Will County in 1970 was 21+9, i+98, an increase of 30.2% since 1960.
Will is the 7th largest county of the 102 counties in Illinois and the county's
growth rate from 1 960 to 1970 was exceeded by only two other counties in the
state. The population pattern for the entire county shews an 11% growth rate
from 1970 to 1973, with a 1973 census of 278,060. Much of Will County is rural
with two heavily urbanised areas, located in the northeastern and northwestern
portions of the county.
•The primary service area of the Community Health Services program consists of
four urbanized townships, Joliet, Lockport, Troy and DuPage, located in the
northwestern quadrant of Will County. The location of these townships is
illustrated in EXHIBIT A. The 1970 population of the primary services area
was 160,960, representing 6h°/o of the entire Will County population. Two town-
ships of the primary service area, DuPage and Troy, were areas of significant
growth from i960 to 1970, each registering a more than 30% growth rate. The
Village of Bolingbrook, in DuPage Township, has experienced the sharpest rate
of growth, from 7»275 in 1970 to 25,519 in 1 97U- The primary service area
also encompasses the City of Joliet, county seat and the largest single munici-
pality in the county with a 1970 population of 80,378. Joliet is the govern-
mental, educational and cultural center of the primary service area.
The primary service area is inter-sected by two federal Inter-State highways,
and is served by five transcontinental highways and four state highways. In
addition, the area is served by six railroads and four inter-city bus lines.
Local mass transportation- is provided by a single bus line which operates six
days per week in three of the four townships of the primary service area.
Health resources include 176 physicians in solo and group practices in Will
County, 150 located in the primary service area. The area is served by two
general hospitals with a total of 983 beds offering physical therapy, intensive
and cardiac care, psychiatric care and accredited schools of nursing, medical
technology and radiologic technology. Other available health services include
twelve long term care institutions with 79U beds and 91 dentists. In addition,
the Will County Health Department, headquartered in Joliet, has divisions deal-
ing with Mental, Dental and Environmental Health, health education and nursing
services. The department also provides heme and school health services, health
counseling, vision and hearing screening services and health referrals.
The continued pattern of rapid growth in Will County, and particularly in the
primary service area, have taxed the capacity of existing resources to meet
the ever- increasing demand for health services.
One effort to meet this increasing need was the development of a physician
rotation program by the Will-Grundy County Medical Society in 1971. Prom
1971 until 1 975 » 2,256 patients, a majority of them public aid recipients,
were assigned to volunteer physicians. Of that number, 2,065 were assigned
during one year as a result of increased publicity about the program. The
Medical Society was forced to cancel the program in March, 1975 as the demand
for services increased and voluntary physician participation decreased. In
April, 1975? the Medical Society joined a number of other community agencies
in a project with the local school district to provide state-required physical
examinations for several hundred children, many of them Medicaid-eligible.
These activities, coupled with efforts to provide services in the Early
Periodic Screening, Diagnosis and Treatment program in solo practice settings,
led to a keener awareness of the needs of the patient relative to total health,
welfare and social services and to recognition of the fact that private physicians
could not handle those needs alone. The Medical Society recognized the fact that
the entire professional community must assume leadership in developing accessi-
bility to the health care system.
Prior to the cancellation of the physician rotation program, the Will-Grundy
County Medical Society was in contact with various community agencies, both
providers and consumers of health services, to discuss possible alternatives
to expanding the existing health delivery system. The Community Steering
Committee, as identified earlier, was formalized as a result of these dis-
cussions.
The Community Steering Committee has met regularly for a period of six months
in a cooperative effort to develop the elements to be included in this model
Community Health Services program.
lanMMwaaMi wm meant*** rOTrirait^sa
scale •• I - 5 miles
.1 „ «» ikia t^nnrt was financed In part through
Z rW«lnnment under .rovlslons of Sec. 701 ot the
Urban Development under proviso
Houston Act of 1934 k» amended
J
GOALS AND OBJECTIVES
One of the primary objectives of most communities, 2nd especially of our
community, is to assure all residents access to the health care delivery
system. The development of a Community Health Services program, assuring
this accessibility, requires the cooperative effort of many facets of the com-
munity, which must include but not be limited to physicians, hospitals, allied
health agencies and social agencies.
The primary goal of this program shall be to provide high quality, comprehen-
sive medical and related health and social services which are economically
available and accessible to the residents of Will County, Illinois. The
initial focus of this program will be directed at providing additional primary
care services to the residents of Joliet, Lockport, Troy and DuPage Townships
who are now experiencing difficulty in obtaining these services. While the
initial scope of the Community Health Services program is restricted to the
four townships in the northwestern quadrant of the county because of the high
concentration of population and the availability of existing health resources,
the services of the program in the future will be available to all residents
of Will County. It is anticipated the services of the program can be extended
into outlying areas of Will County as the program develops.
To attain this goal, it will be necessary to meet the following objectives:
A.
To provide additional primary care services
B.
Improve the continuity and quality of health care services
0.
0.
Containment of cost through better utilization of limited and
expensive facilities and manpower resources
Preserve and improve the physician 'patient relationship.
PROBLEM DEFINITION
The population of Will County, particularly in the primary service area, is
confronted with a number of barriers to adequate health care services. These
barriers are particularly acute in that segment of the population of low and
moderate incomes and the aged. The locally identified barriers to health
services are:
A. Unavailability of health services
The number of physicians in the areas of family practice, pediatrics, internal
medicine and obstetrics has steadily declined since 1961+- Approximately,
53 physicians left private practice in Will County between 1964 and 1975* U6 in
the above-mentioned areas. During the same period, 67 physicians established
practices in the area but only 26 in primary care, some in part-time practice,
with the result of a net loss of 22 1/2 primary care physicians. During the
same period, the population of the county has increased over 30%. The re-
sulting overload has caused many physicians to restrict the size of their
practices. 'These restrictions of practices resulted in an increase of crisis-
oriented delivery in the local hospital emergency rooms particularly for the
low-income segment of the population.
B. Physician/patient ratio
The ratio of primary care physicians to patients in the primary service area
is 1/3, 1+99 » however, physicians geographically located within the primary
service area do not restrict their practices to residents of that area. Most
residents of rural areas of Will County are dependent on health care facilities
within the primary service area, thus the ratio of primary care physicians to
the population of the county is 1/6,0U5« Ln addition, the medical service
area for these same physicians includes an additional 100,000 people from ad-
jacent surrounding counties, so the functional primary care physician/patient
ratio is 1. 8,219.
C. Lack of education of the general public in health matters
This barrier is evident in the utilization of existing health resources, a
lack of understanding of the value of preventive medicine, inability to
understand and follow treatment regimens and communication gaps between
providers and recipients.
D. Lack of transportation
There is no regularly scheduled, convenient public transportation available
to all of the primary service area and few facilities exist for transportation
of the aged or handicapped or others unable to use public transportation.
Public transportation is available only in the immediate environs of the Cities
of Joliet, Lockport and Rockdale, during daylight hours, six days per week.
_nad.eau.ate dollar income
Many citizens of low and moderate incomes, not Public Aid clients, are finding
the increasing costs of health care delivery difficult to meet. This problem
is acute among the aged on fixed incomes.
3F. Inadequate provider re-imbursement
The use of a fee schedule, rather than the payment of usual and customary
fees, by the Illinois Department of Public Aid and the lengthy delays in
these payments and other administrative difficulties, combined with already
heavy patient loads, have discouraged physician acceptance of IDPA patients.
These locally identified barriers to health services serve to perpetuate cycles
of illness, limited health awareness and education, and poverty. These barriers
particularly frustrate the poor and alienate them in their relation to society.
It is the task of the professional health and health-related communities to
involve the total community in developing a mechanism to remove these barriers.
With this in mind, the following demographic information on the primary service
area was considered:
CHART I
How many people live in these four townships ?
WILL COUNTY
U.S. CENSUS (
1970
JULY 1, 1973
1970)
% 65 &
ESTIMATED
TOWNSHIP
TOTAL POPULATION
OVER
TOTAL POPULATION
JOLIET
96,001
10.5
9U,527
DUPAGE
20,001
1.1*
32,521
LOCEPORT
33,35V
U.7
36,73U
TROY
9,-95
2.0
12,151
TOTAL OP
k TWP.
159,237
175,933
Will County
2U7, -25
7-2
27S, 060
Illinois State 11
,113,976
9.3
11,176,356
Source :
U.S.
Census
it has been determined for the
purposes
of the
Community H
ealth
Services program
that the greatest
potential for
•„se of
alterna
system exists in that
ulation with
j nconies
of |10,i
D00 ter year
or 1
ess. 'This should
not oe interpreted
to mean that
the _ar
vices c
tern would be denied to
zzhes residents of
'.va j — County
*.v*no exce
ed that
as 5 ump o i on zi potential use 1.3 rs-mi crcsci oy the ic,ct that 3«2C5 P^^SliG a-.d
recipients reside within the primary service area, representing a majority of public
aid clients in Will County and whose incomes can be reasonably estimated to fall
under 310,000 per year.
CHART II
TOWNSHIP 1969 % of Families' Earnings
Less than 37 » 000 - Col. 1
^7,000 o , 999 -j. 2
LuPage 6.0 11+.1+ 20.1+
Joliet 20.6 21.1 1+1-7
LockDort 13-7 '9.5 33-2
Troy 6.9 12.1+ 19-3
Source: Northeastern 111. Planning Commission
Suburban Factbook, 1973, Table 17
Median Income
1970
DuPage
Joliet
Lockport
Troy
312,630
311,086
311,658
313,503
Number of Number of families with
Families children 13- under
2U,1S1+
7,150
2,730
3,711
13,U39
U,617
2,036
Source: CHP, INC. Metropolitan Chicago
Number of Families Below 310.000 in 1969
901
10,081+
2,373
£26
13,831+
Source: From tables above ( # of Families
from CHP, Inc. and Income from NIPC)
Number of "persons cer household:
Joliet Twp. 3*12
LuPage 1+.1+0
Lockport Twp. 3«51+
Troy Twp. 3.87
Will County 3«U3
State of Illinois 3«09
LuPage
Joliet
Lockport
Troy
J. 3. Census Bureau - "970
For ice-mentation purposes, the figure of 3 persons per family was used to
calculate the following information:
1 3 » - CLl families i 3-0 persons per family a 1+1 > 652 people
This represents 39% of the population of the primary service area and it is
reasonable to assume that this segment of the population is most severely ef-
fected by one or more of the previously identified barriers to adequate health
care.
The demographic information presented here provides a reasonable framework
for initial planning to remove these barriers to the delivery of health care
services. The Community Steering Committee has determined its course of action
to be:
A. To identify several alternatives for community consideration
3. To develop a methodology in which the community can evaluate and
select from those alternatives.
T> (I'll i ' — - ->-£ vr n ,"*n > -i^-.t>,tt~ i — rr>->r Tr1 " THTT OO/VTJ ITT
Jhe first element of a Community Health Program is the development of a Community
Health Council which should draw upon the common knowledge, experience and interest
of the community ' s health care providers, civio leaders and residents. The com-
munity Health Council should not include representatives of all community groups
and organisations out should consist of a representative cross-section of the
total community. A categorical breakdown of these groups could be:
A. Froviders of health services
1 . Health professionals
Will-Grundy County Medical Society
Will County Dental Society
Public Health nurses
2. Health institutions
St. Joseph Hospital
Silver Cross Hospital
Will County Health Department
Salem Home
Sunny Hill Nursing Home
3. Voluntary health and welfare agencies
Will County Unit, American Cancer Society
Easter Seal Rehabilitation Center of Will County
American Red Cross, Western Will County Region
Joliet-Will County Community Action Agency
Will County Department of Public Aid
Illinois Department of Children and Family Services
B. Consumers of health services
1 . Industry
Will-Grundy Manufacturers Association
Caterpillar Tractor Company
United States Steel Corporation
2. Business
Joliet Region Chamber of Commerce
3. Non-health professionals
Will County Bar Association
U. Farm organisations
Will County Farm Bureau
5. Organized labor
Will County 3uilding Trades Council
International Association of Machinists and Aerospace Workers Local 55 1
6. Religious leaders
Diocese of Joliet
Joliet Ministerial Alliance
7. Educational leaders
q, Will County Educational Service Region
Joliet Township Hi^i School District 201+
Valleyview School District 365-U
y. Local governmental leaders
Will County
City of Joliet
Village of Romeoville
City of lockport
Village of Bolingbrook
9. Cooperative extension services
Will County Home Extension Association
University of Illinois Cooperative Extension Service
Representatives of each of these categories should "be formally invited to join in
forming a Community Health Council. Each would be expected to function as a trustee
of the community rather than representatives of individual or organization interest.
A general meeting should he called to discuss the formalization of a Community Health
Council and to reach agreement on the need for united community action. Since much
work has been completed by the Community Steering Committee, the new Council should
be able to complete its own organization and to begin review of alternatives. The
new Council would then assume responsibility for planning and implementation of the
Community Health Services program.
The Council may wish to function as a whole or appoint committees to perform certain
functions. The use of Committees and possible functions to be performed are as
follows :
1 . Committee to develop constitution and by-laws
2. Committees to select consultants to work with the Council and its Committees
if needed in those areas where there is limited expertise:
- To identify community groups and organizations; also might assist
in grant applications, data gathering and state and national con-
tacts for information and assistance.
3. Committee to finance the Council and its programs:
- To collect and analyse data relative to funding mechanisms by identi-
fying sources of payment for Council services, including other
government and /or local funding, private individuals, foundations,
insurance companies, community fund drive, business, industry, etc.
_. lcmmi":~ee ~c inform "he ;cmmuni~y of the Council's ac~ivx~ies:
- To assist other Committees in their relationships within and cu-side
the Community.
-10-
Ii. Committee to inform the community of the Council's activities cont'd:
- Sevres as ccmmunication medium between the Council and community
residents. Develop and implement publicity campaign regarding
program description, progress, and success. To recommend action
programs to the Council that may he approved by the community residents
and meet their needs.
3. Community Coordinating Committee:
- To coordinate, gather information, and determine those community
groups and organisations that can best assist the Council in its
activities.
6. To be responsible for functions outlined in Program Evaluation Section.
It is estimated the Community Health Council can complete the following
objectives by April, 1976:
1 . Begin review of alternatives
2. Select a Board of Directors and complete legal incorporation
3. Formalize committee structure
Ij.. Develop and adopt constitution and by-laws
It is estimated the Community Health Council can complete the following
objectives by June 1, 1976:
1 . Select alternatives
2. To collect and analyze data relative to funding mechanisms by identifying
sources of payment to include governmental and/or local funding.
The Council will have the services of a part-time staff person from January 1, 1976
until June 30, 1976 through the cooperation of the Will-Grundy County Medical Society.
Other technical assistance to the Council can be provided by the Will-Grundy-Kankakee
Comprehensive Health Planning Council and by the Department of Rural and Community
Health of the American Medical Association. It is anticipated that within the six
month period, the Council should be able to determine if continued staffing is
needed and to determine a payment mechanism.
- 11 -
c
(the alternatives section will be inserted here)
c
PROGRAM EVALUATION
Evaluation is an essential part of effective management and should be performed
on a continuous basis in order to strengthen the program. A method of evaluation
should be incorporated into all aspects of the program during its development.
Each program component should be reviewed periodically to determine accomplishments
in relation to operational objectives. This review of actual services performed
and resources expended to planned services and resources should include an assess-
ment of the effectiveness and efficiency, as well as, the acceptability of the
services provided.
As a method of evaluation, this program will attempt to develop a data base
generated by the direct services it provides. All visits to the program will be
recorded as will the direct services supplied. The number and types of referrals
will be recorded as well as the number of vehicle trips. These factors will gene-
rate a cost per patient for access to health care. Data will also be accumulated
as to the number and type of home visits provided.
At the end of the first six months, and each six months thereafter, documents will
be solicited from both physicians and patients. These will give some indication
of patient attitude as well as physician attitude. Over a period of time, this
will provide an indication of attitudinal change on the part of citizens, health
care providers and health care institutions.
It shall be the responsibility of the Program Evaluation Committee to develop the
proper documents to gather data, to review the data generated and to make appropri-
ate recommendations.
To emphasise the importance of program evaluation, and to assure the quality of
services rendered, it is anticipated the Council will request the assistance of
the Quad River Foundation for Medical Care for the development of criteria for
care services. It is anticipated this assistance will be sought at such time when
the Quad River Foundation for Medical Care can develop a mechanism for ambulatory
care review.
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